VHA/DoD Clinical practice Guideline for the Management of ...

VHA/DoD CLINICAL PRACTICE GUIDELINE FOR THE 

MANAGEMENT OF POSTOPERATIVE PAIN 

Veterans Health Administration 

Department of Defense

Prepared by: 

THE MANAGEMENT OF POSTOPERATIVE PAIN 

Working Group 

with support from: 

The Office of Performance and Quality, VHA, Washington, DC 

& 

Quality Management Directorate, United States Army MEDCOM 

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JULY 2001/ 

UPDATE MAY 2002

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE 


TABLE OF CONTENTS 

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VHA/DoD Clinical Practice Guideline for the 

Management of Postoperative Pain 

TABLE OF CONTENTS 

INTRODUCTION 

A. ALGORITHM & ANNOTATIONS 

• Preoperative Pain Management.....................................................................................................1 

• Postoperative Pain Management ...................................................................................................2 

B. PAIN ASSESSMENT 

C. SITE-SPECIFIC PAIN MANAGEMENT 

• Summary Table: Site-Specific Pain Management Interventions ................................................1 

• Head and Neck Surgery..................................................................................................................3 

- Ophthalmic Surgery 

- Craniotomies Surgery 

- Radical Neck Surgery 

- Oral-maxillofacial 

• Thorax (Non-cardiac) Surgery.......................................................................................................9 

- Thoracotomy 

- Mastectomy 

- Thoracoscopy 

• Thorax (Cardiac) Surgery............................................................................................................16 

- Coronary Artery Bypass Graft (CABG) 

- Minimally Invasive Direct Coronary Artery Bypass (MID-CAB) 

• Upper Abdominal Surgery ...........................................................................................................19 

- Laparotomy 

- Laparoscopic Cholecystectomy 

- Nephrectomy 

• Lower Abdominal and Pelvis Surgery.........................................................................................26 

- Hysterectomy 

- Radical Retropubic Prostatectomy 

- Inguinal Hernia 

• Back/Spinal Surgery .....................................................................................................................30 

- Laminectomy 

- Spinal Fusion 

• Surgery of Extremities/Vascular Surgery...................................................................................33 

- Total Hip Replacement 

- Total Knee Replacement 

- Knee Arthroscopy and Arthroscopic Joint Repair 

- Amputation 

- Shoulder – Open Rotator Cuff Repair or Arthroscopic Sub-Acromial Decompression 

- Vascular Surgery 

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D. OPTIONS FOR POSTOPERATIVE PAIN MANAGEMENT 

NON-PHARMACOLOGIC MANAGEMENT 

• Cognitive Modalities .......................................................................................................................1 

- Distraction, Relaxation, and Biofeedback 

- Hypnosis 

• Physical Modalities..........................................................................................................................5 

- Transcutaneous Electrical Nerve Stimulation (TENS) 

- Cold 

- Heat 

- Exercise 

- Positioning 

- Immobilization/Rest 

- Massage 

- Accupuncture 

PHARMACOLOGIC MANAGEMENT 

• Routes of Administration................................................................................................................2 

• Pharmacologic Management..........................................................................................................9 

- OPIOIDS....................................................................................................................................9 

Summary Table – Site Specific Pain Management Interventions - Opioids 

Table OP1 – OPIOIDS: Mechanism of Action, Contraindications, Other Considerations 

Table OP2 – OPIOIDS: Dosing and Pharmacokinetics 

Table OP2.5 – OPIOIDS: Dosage Formulations 

Table OP3 – OPIOIDS: Drug Interactions 

Table OP4 – OPIOIDS: Equianalgesic Dosing 

Table OP5 – OPIODS: Dosage Formulations 

- Acetaminophen and NSAIDs...................................................................................................49 

Summary Table – Site Specific Pain Management Interventions - NSAIDs 

Table NS1 – NSAIDs: Mechanism of Action, Contraindications, Other Considerations 

Table NS2 – NSAIDs: Dosing and Pharmacokinetics 

Table NS3 – NSAIDs: Drug Interactions 

- Local Anesthetics.....................................................................................................................62 

Summary Table – Site Specific Pain Management Interventions– Local Anesthetics 

Table LA1 – Local Anesthetics: Mechanism of Action, Contraindications, Other 

considerations 

Table LA2 – Local Anesthetics: Pharmacologic, Pharmacokinetic, and Clinical 

Characteristics 

Table LA3 – Local Anesthetics: Adverse Effects 


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- Glucocorticoids........................................................................................................................72 

Summary 

Table GC1 – Comparison of glucocorticoid agents in order of increasing potency and 

duration. 

Table GC2 – Dosing and routes of administration of glucocorticoids with postoperative 

analgesic efficacy 

Table GC3 – Dosing and administration of glucocorticoids fpr [pstoperative and e[idural 

morphine-related nausea or vomiting 

E. EDUCATION FOR PAIN MANAGEMENT 

• General Preoperative Education....................................................................................................1 

• Discharge Education .......................................................................................................................5 

• The Pain Trajectory Relative to The Operative Procedure.......................................................12 

F. APPENDICES 

• APPENDIX A: Guideline Development Process ..........................................................................1 

• APPENDIX B: Participant List .....................................................................................................1 

• APPENDIX C: Bibliography..........................................................................................................1 


VHA/DoD CLINICAL PRACTICE GUIDELINE FOR 


INTRODUCTION 

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Postoperative Pain Management 

Acute postoperative pain is a significant issue for surgical patients in the Veterans Health Administration 

(VHA) health care system, the Department of Defense (DoD) health care system, and in the nation at large. 

In 2000, more than 360,000, combined inpatient and outpatient, surgical procedures were performed in the 

VHA (VHA Patient Care Services, 2001), and approximately 475,000 procedures were done in the DoD 

system (TRICARE, 2001). Effective pain management is associated with patient satisfaction, earlier 

mobilization, shortened hospital stay, and reduced costs (AHCPR, 1992). Despite these benefits, there are 

substantial numbers of patients who suffer from postoperative pain. To address this problem, the Agency 

for Health Care Policy and Research (AHCPR) Acute Pain Management Clinical Practice Guideline (CPG) 

was released in 1992. The VHA added pain as a fifth vital sign as of October 2000 (VHA, 2000). Since 

then, therapeutic advances, outcome studies, and the publication of the Joint Commission on Accreditation 

of Healthcare Organizations’ (JCAHO) Pain Management Standard for 2001 have refined the practice of 

pain management, (2001). It is therefore essential that the VHA and DoD develop a systematic approach to 

pain management that assures that pain is recognized and treated promptly and effectively. This guideline 

is part of a system-wide approach to pain management that is designed to reduce pain and suffering for 

patients experiencing acute and chronic pain. 

Alleviation of pain and suffering, especially when it occurs as a consequence of treatment, is a priority for 

all health professionals. The subjective nature of the pain experience requires flexibility, compassion, and 

understanding on the part of the health care practitioner. This acute postoperative pain guideline was 

written from a specific procedural perspective and is intended as a tool to enhance the practitioner’s clinical 

skills by presenting therapeutic options with supporting information. It does not dictate one approach, but 

provides principles and guidance to effective, safe, and timely pain management. As a web-based 

guideline, it can be used in a variety of ways—providing information on algorithms, assessment, special 

needs, interventions, and planning for pain management at the chosen level of detail. In addition, as 

improvements in pain management are realized, they can be rapidly disseminated. 

Surgical procedures inevitably produce tissue trauma and release potent mediators of inflammation and 

pain (NHMRC, 1999). New treatment techniques and drugs, and the increased attention to pain 

management in general, have led to opportunities to improve the care of patients with pain. The VHA/DoD 

Guideline for the Management of Postoperative Pain is intended to improve the quality of care and 

facilitate the management of patients with postoperative pain. The guideline focuses on the assessment, 

diagnosis, treatment, management, and follow-up of these patients. 

Goals of the Guideline 

The VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain is intended to assist 

medical care providers in all aspects of care for patients with postoperative pain. The system-wide goal of 

using evidence-based guidelines is to improve the patient’s outcome. In general, the expected outcome of 

successful implementation of this guideline is to improve the postoperative experience, and to reduce the 

morbidity that is associated with unmanaged pain. To achieve this goal, the guideline addresses the 

following critical points: 

• Efficient and effective initial preoperative assessment. 

• Developing a collaborative pain management plan with the patient. 

• Providing appropriate education for the patient and family. 

• Optimizing the use of therapeutic techniques to control pain . 

• Reducing the incidence and severity of postoperative pain. 

• Minimizing preventable postoperative complications and morbidity. 

The current guideline represents a major step toward achieving this goal for patients in the VHA and DoD. 

However, as with other CPGs, challenges remain to develop effective strategies for guideline 

implementation and evaluation of the effect of guideline adherence on clinical outcomes. 

Introduction 

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This guideline is not intended as a standard of care. Standards of care are determined on the basis of all 

clinical data available for an individual case and are subject to change as scientific knowledge and 

technology advances and patterns evolve. The ultimate judgement regarding a particular clinical procedure 

or treatment course must be made by the individual clinician, in light of the patient’s clinical presentation, 

patient preferences, and the available diagnostic and treatment options. The guideline can assist care 

providers, but the use of a CPG must always be considered as a recommendation, within the context of a 

provider’s clinical judgment, in the care for an individual patient. 

For the Future 

The inability of consumers and health care purchasers to determine if medical care is appropriate and 

effective has given rise to the concept that the health care system should be held accountable for what is 

done and what outcomes are achieved. The quality and cost of care are being scrutinized at every level of 

the health care system. CPGs have been introduced in many settings as one way to reduce variations in the 

delivery of care, thus improving the quality of the care. However, experience has demonstrated that it is 

difficult to affect clinicians’ behavior through the use of practice guidelines. The VHA and DoD are 

developing a variety of tools for implementing the guidelines and a set of indicators to measure the impact 

of guidelines on the quality of the care. 

Modifications to the guideline are anticipated as lessons are learned and new research and practice-based 

evidence become available. The developers believe that this guideline should always be considered “a work 

in progress." 

Introduction 

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KEY POINTS OF THE PAIN MANAGEMENT GUIDELINE 

The experts concluded the guideline process by summarizing the key points: 

• An effective pain program is based on an understanding of the scientific foundation of 

postoperative pain and pain management options. 

• Preprocedural patient evaluation is necessary to provide safe and effective pain management. 

• Medical or surgical stabilization must be provided prior to or in conjunction with effective pain 

management. 

• Pain management requires systematic patient assessment postoperatively, at scheduled intervals, 

in response to new pain, and prior to discharge. 

• The components of a good assessment will vary depending on the patient’s situation, but should 

include both severity of pain and its impact on functioning. 

• Education of the patient and those involved in patient care is a central component of effective pain 

management: 

− 

− 

Pain management education should provide the patients with realistic expectations about pain, 

the postoperative and discharge treatment plan, and expected outcomes. 

Pain management education decreases emotional distress, enhances coping skills, and enables 

the patient to participate in treatment. 

• Postoperative pain management should be multimodal and individualized for the particular 

patient, operation, and circumstances. Understanding the range of available interventions and 

considering the type of surgery are essential to safe and effective pain management. 

• Selection of a pain management option should be determined by balancing the advantages, 

disadvantages, contraindications, and patient preference. In most patients, more than one modality 

will be needed for successful pain management. 

• Interventions for postoperative pain management include both pharmacologic (using the main 

classes of medication: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local 

anesthetics) and non-pharmacologic (cognitive and physical modalities). 

• Evaluation of the balance between pain control and side effects should be routine, timely, and 

specific. The management plan should be modified, if indicated. 

• The discharge plan should include a plan for continued pain management. It should be in place 

prior to discharge and be effectively communicated to the patient and their caregiver if 

appropriate. 

Introduction 

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EDITORIAL PANEL OF THE WORKING GROUP 

Mary Dallas, MS, PT, CWS 

Physical Therapist/Research 

Oxford, CT 

Francine Goodman, PharmD 

Clinical Pharmacy Specialist 

Hiles, IL 

Susan Hagan, ARNP, MS 

Coordinator, Pain Programs 

Tampa, FL 

Andrew Kowal, MAJ, MC, USA * 

Chief, Pain Clinic 

Vashon, WA 

Jack Rosenberg, MD * 

Clinical Assistant Professor, Anesthesia 

Ann Arbor, MI 

Richard Rosenquist, MD * 

Associate Professor of Anesthesia 

Iowa City, IA 

Diana Ruzicka, RN, MSN, AOCN, CNS 

Oncology Clinical Nurse Specialist 

Yorktown, VA 

Charles Sintek, MS, RPh, BCPS 


Denver, CO 

Jane Tollett, PhD, RN 

National Director, Pain Management Strategy 

Washington, DC 

Dennis C. Turk, PhD 

Professor of Anesthesiology and Pain Research 

Seattle, WA 

* Co-Chairperson FACILITATOR 

Oded Susskind, MPH 

PARTICIPANTS OF THE WORKING GROUP 

Phyllis K. Barson, MD 

Chair, Department of Anesthesia 

Silver Spring, MD 

Thomas Calhoun, MD 

Associate Medical Director 


Michael Craine, PhD 

Director, Interdisciplinary Pain Team 

Denver, CO 

Mark Enderle, MD 

Chief of Staff 

Fayetteville, AR 

Paul M. Lambert, DDS 

Chief, Dental Service 

Dayton, OH 

Thomas Larkin, MAJ, MC, USA 

Department of Anesthesia 


Tamara Lutz, RN, MN CPHQ 

Nurse Manager 

Fort Eustis, VA 

Alice M. Savage, MD, PhD 

Consultant to DVA 

Windsor, MA 

David Spencer, MD 

Infectious Disease 

Bethesda, MD 

Timothy Ward, MD 

Chief, Oral Maxillo Facial Surgery 

Gainsville, FL 

CONSULTANTS AND TECHNICAL WORKFORCE 

Diane Boyd, PhD 

John Brehm, MD 

Sara Curtis 

Rosalie Fishman, RN, MSN 

Verna Hightower 

Sarah Ingersoll 

Christine Winslow 

Introduction 

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ALGORITHM AND ANNOTATIONS 

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Algorithm and Annotations Page 1

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ANNOTATIONS 

A. Patient is a Candidate for Procedure/Operation 

Patients managed by this guideline are adults (age > 17) within the VHA and DoD health care systems who 

are undergoing a procedure or operation and for whom pain management is warranted. In an emergency 

procedure, implementation is determined by the time available and patient status. 

B. Conduct Preoperative Patient Evaluation 

OBJECTIVE 

Identify factors, both clinical and psychosocial, that may impact the postoperative pain management plan. 

ANNOTATION 

Most of the information needed to develop a postoperative pain control plan is contained in a routine 

history and physical examination. In order to provide effective pain control, the clinician should pay 

particular attention to the following specific questions: 

Chief Complaint—What is the planned surgical procedure? What are the circumstances under which the 

procedure is being performed? Is the procedure elective or emergent? Does the patient have acute pain? 

Past Medical History—What concurrent medical problems are present? Are there any known problems 

with coagulation? Are there congenital abnormalities? Are there concurrent neurologic diseases such as 

multiple sclerosis, muscular dystrophy, stroke, mental dysfunction, amyotropic lateral sclerosis or 

peripheral neuropathy, among others? Is there a history of prior trauma to the proposed surgical site? Is 

there a history of infection or respiratory difficulty? 

Past Surgical History—Is there any history of surgery (e.g., spine surgery)? 

Medications—What medications is the patient currently taking? Is the patient taking any anticoagulants 

that would alter choices for postoperative pain control? Is the patient taking opiates on a chronic basis? Is 

the patient taking any monoamine oxidase inhibitors (MAOIs) medications? 

Allergies—Is the patient allergic to any of the opiates, local anesthetics, NSAIDs, agonist-antagonists, 

corticosteroids or any other medications commonly used to provide postoperative pain control? 

Psychosocial History—Is there any history of drug or alcohol abuse or addiction? 

Past Pain History—Does the patient have chronic pain? How is the chronic pain currently being treated? 

What postoperative pain control methods were used successfully or unsuccessfully? Did the patient 

develop side effects from the chosen method? 

Physical Examination—Are there patient characteristics (i.e., physical or mental abnormalities) that 

preclude the use of certain postoperative pain control techniques? Will the surgical procedure involve the 

insertion areas for regional or neuraxial analgesia techniques? Are there signs of infection at the site of 

proposed needle insertion? 

Imaging Studies—Are there physical anatomic abnormalities, either congenital or acquired, that involve 

the proposed site for a pain control technique? 


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Pain Assessment: 

If the patient reports any pain, a pain assessment needs to be completed. This assessment may help in 

evaluation of postoperative pain. See the “Pain Assessment” section of this guideline for detailed 

information on pain assessment. 

C. Discuss Treatment Options with Patient and Develop Collaborative Plan 

OBJECTIVE 

Establish a collaborative approach for pain management based on the patient’s understanding about, and 

acceptance of, available treatment options. 

ANNOTATION 

• Review with the patient the available options for pain prevention and control including physical and 

cognitive non-pharmacologic interventions, as well as pharmacologic management (i.e., PO, IM, 

IV/PCA, regional, epidural, and spinal). Consider a multimodal approach. 

• Answer the patient’s questions and provide patient education material (see section “Education For Pain 

Management”). 

• Patient refusal is a contraindication to any treatment option. 

• The treatment plan must be acceptable to the surgeon as well. 

For a review of the options, refer to the Summary Table in the section “Site-Specific Pain Management.” 

D. Provide Patient and Family Education 

OBJECTIVE 

Prepare the patient for treatment interventions that promote postprocedural comfort. 

ANNOTATION 

One of the primary concerns of patients and their significant others is the pain and discomfort following 

surgery. Patients respond differently to pain depending on their prior experience, emotional state, and level 

of anxiety. Individualized preoperative education may favorably alter this experience by reducing anxiety 

and allaying preconceived fears (Voshall, 1980). 

Information to be included in pain education preoperatively should address the following: 

Expectations: 

• Effect of pain management on healing and reducing complications after surgery 

• Expectation of pain and individual nature of pain experience. Review the expected severity and 

duration for specific type of surgery. See Table ED-1: Patient Education Trajectory Table in the 

“Education for Pain Management” section. 

• Expectation that pain can be controlled following surgery 

• Goals for pain relief 

Assessment: 

• Ways of assisting in the measurement of pain 

• What patients should report regarding pain and its treatment 


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Postoperative plan: 

• Postoperative pain management plan (i.e., specific information about the interventions) 

• Importance of patient involvement in the plan (e.g., controlling PCA) 

Interventions: 

• How quickly the pain intervention should work 

• When to ask for pain medication 

• Patient concerns about the intervention (e.g., side effects, addiction, and complications) 

• Non-drug measures for pain relief (explain those applicable) 

− Relaxation 

− Physical modalities 

− Distraction 

− Hypnosis 

DISCUSSION 

Information should be presented to patients more than once, and in more than one way (e.g., pamphlets, 

videos, and discussion ) in order to achieve the desired effect. The information provided in the “Education 

for Pain Management” section of this guideline is comprehensive. The clinician should apply the relevant 

sections to the individual patient’s needs. 

Opinions of respected authorities support the efficacy of preoperative education for pain control. One 

article (Owen et al., 1990) included a patient survey. 

EVIDENCE TABLE 

Intervention Sources of Evidence QE R 

1 Individualized preoperative education Voshall, 1980 

III B 

may favorably alter the pain experience. Owen et al., 1990 

III A 

QE = Quality of Evidence; R = Recommendation (See Appendix A) 

E. Initiate Preemptive Measures for Pain Management, as Indicated 

OBJECTIVE 

Initiate interventions prior to operation in order to prevent or enhance postoperative pain control. 

ANNOTATION 

Some procedures/interventions will be more beneficial if the patient had prior experience or training (e.g., 

hypnosis and relaxation technique) prior to the operation. For certain procedures, specific interventions 

need to be undertaken before the procedure (e.g., see amputation in the “Site-specific Pain Management” 

section). Detailed information on interventions can be found in the “Site-specific Pain Management” 

section and in the “Pharmacologic Management” sections of this guideline. 

F. Patient with Acute Pain after Procedure/Operation 

Patients managed by this algorithm are those who have undergone a procedure or operation with analgesia 

or anesthesia. 


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DISCUSSION 

Understanding pain physiology and the mechanism by which treatment can prevent or control pain, may 

help the clinician in choosing the optimal therapy and providing appropriate care. 

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential 

tissue damage or described in terms of such damage” (Mersky & Bogduk, 1994). The three major ‘types’ 

of pain can be defined as nociceptive, non-nociceptive (neuropathic), and idiopathic. 

Nociceptive Pain: 

Starting with the site of actual tissue damage and ending with the perception of pain is an extremely 

complex series of events collectively known as nociception, which can be divided into four processes: 

1. Transduction 

2. Transmission 

3. Modulation 

4. Perception 

Transduction refers to the process in which noxious stimuli are translated into electrical energy at sensory 

nerve endings and then transmitted to the spinal cord. 

Transmission refers to propagation of the impulse through the sensory nervous system by primary afferent 

fibers (Meeker & Rothrock, 1999) which synapse in the dorsal horn of the spinal cord and second-order 

neurons in the lamina of the dorsal horn, ascending neurons projecting to brain stem, thalamus, and 

thalamocortical projections (Moser et al., 1997). 

Modulation denotes the alteration of nociceptive information by endogenous mechanisms. This modulation 

may result in attenuation or amplification of the initial signal. Perhaps the most important is the dorsal 

horn of the spinal cord. 

Perception reflects the effect of the nociceptive information on the existing psychological framework. 

Perception is the emotional and physical experience of pain. This experience can alter the way subsequent 

pain experiences are perceived. 

The most effective postoperative pain management plan attempts to attack all four phases of nociception. 

For example, NSAIDs can decrease the tissue inflammatory response (transduction); neural blockade 

inhibits signals from reaching the CNS (transmission); opiates can enhance the central inhibitory input at 

the spinal cord (modulation); and thorough pre- and postoperative teaching can help prevent and manage 

anxiety (perception). 

Nociceptive pain results from activation of the physiologic processes mentioned above in somatic or 

visceral structures. It often is related directly to the extent and location of tissue damage. Nociceptive 

somatic pain is often described as sharp, aching, throbbing, and/or pressure-like, whereas nociceptive 

visceral pain is poorly localized; cramping or gnawing if a hollow viscus is involved or aching and sharp if 

a capsule or mesentary tissue is involved. Most postoperative pain falls into this category. 

Non-nociceptive Pain: 

Non-nociceptive pain (neuropathic) results from abnormal function in the central or peripheral 

somatosensorysystem. This pain may occur when the normal physiologic process of nociception has been 

altered, producing different subjective and objective findings. Usually, the subjective presentation is of 

burning, stabbing, or lancinating (lightning bolt) pain. 

Idiopathic Pain: 

Idiopathic pain is pain that can not be explained with organic pathology. 


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G. Determine Medical/Surgical Emergency Based on Vital Signs 

OBJECTIVE 

Rapidly determine, in the immediate postoperative period, whether a medical and/or surgical emergency 

exists, and whether the patient is medically or surgically unstable. 

ANNOTATION 

The postoperative evaluation must begin with a determination of whether there is need for emergency 

action, including immediate life-saving measures and/or immediate referral to an intensive level of care. 

This assessment consists of two levels: 

1. Immediate assessment of the patient’s vital signs: 

• Temperature 

• Pulse 

• Blood pressure 

• Respiratory status 

• Initial assessment of pain 

2. More thorough but expeditious assessment: 

This phase of the assessment focuses on problems that may occur in a postoperative patient. It is 

important to convey to the patient and/or significant others the rationale and steps to be taken in 

this phase of the assessment. 

• Respiratory 

- Airway obstruction (e.g., problems with positioning of an endotracheal tube, poor 

positioning of the neck by obstruction by the tongue, and hemorrhage in the neck 

following such procedures as thyroidectomy) 

- Laryngospasm 

- Bronchospasm 

- Hypoxemia, from a variety of causes – including sedation, intrapulmonary shunting, 

inadvertent administration of oxygen-poor inspired gases, pneumothorax, pulmonary 

edema, pulmonary embolism, pain causing decreased thoracic and/or diaphragmatic 

excursion, and failure of reversal of neuromuscular blocking agents. Pulse oximetry is 

critical to assessment for hypoxemia. 

• Circulatory 

- Hypotension from a variety of causes 

- Surgical bleeding/pneumothorax-including hypovolemia, cardiogenic shock, and septic 

shock. Prompt identification is essential to prevent hypoperfusion of vital organs. 

- Tachycardia 

- Hypertension—may be secondary to preexisting hypertension or may be related to the 

surgical procedure because of pain, hypercapnea (from hypoventilation), hypoxemia, or 

excessive intravascular fluid volume. 

- Dysrhythmias—predisposing factors include electrolyte imbalance (especially 

hypokalemia), hypoxia, dysphoria, hypercapnia, metabolic alkalosis and acidosis, and 

preexisting heart disease. 

• Neurologic: 

- Failure to regain consciousness is most commonly due to the continued effect of 

anesthesia agents, sedatives, and preoperative medications. However, the clinician must 

consider other causes, such as hypothermia, hypoglycemia, hyperglycemia, hypoxia, and 

cerebrovascular event. Agitation may be from pain, but may also be due to hypoxia, 

metabolic causes, or intracerebral events. 

• Pain: 

- Evaluate any new, acute unexpected reports of pain that are not related to the operation. 


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DISCUSSION 

• Nausea and vomiting: 

- Nausea and vomiting are the most common postoperative complications, reported to 

occur in 90 percent of inpatient surgeries and 4 percent of outpatient surgeries. This 

problem is influenced by choice of anesthetic, antiemetic, and the type of surgery, and 

may lead to aspiration complications. 

Rapidly assessing the patient’s clinical status following a surgical procedure is of extreme importance in 

ensuring a successful outcome. There are guidelines, which have been developed by national organizations, 

that may be helpful in organizing the approach to this process. The American Society of Anesthesiologists 

has promulgated Standards for Postanesthesia Care, available on the Internet at http://www.asahq.org/ 

(ASA, 1994). The Association of Perianesthesia Nurses (ASPAN) developed protocols and standards for 

the responsibilities of postanesthesia care unit (PACU) nurses. These guidelines are also available on the 

Internet at www.aspan.org. 

Studies of the relative frequency of occurrence of postoperative complications have shown the following 

for inpatient surgical patients (Hines, 1992). 

• Nausea and vomiting—42% 

• Airway problems—30% 

• Cardiovascular complications—25% 

• Central nervous system—3% 

Respiratory Complications: 

The major respiratory complications encountered in the PACU are airway obstruction, hypoxemia, 

hypercapnea, and aspiration. Rose defined these events as critical respiratory events (CREs). Out of 

24,157 consecutive PACU admissions, the incidence of CREs in patients who had received general 

anesthesia was 1.3 (Rose, 1994). Factors which increased this risk included increased age, obesity, long or 

emergency operations, use of opioids, and choice of anesthesia agent. Patients with CREs were more likely 

to require ICU admission. 

Circulatory Complications: 

Over half of the patients who develop hypertension postoperatively have had preexisting hypertension and 

experience an increase secondary to discontinuation of their antihypertensive agent in the perioperative 

period (Gal & Cooperman, 1975). If hypertension occurs postoperatively, it usually does so within 30 

minutes of the end of the procedure (Gal & Cooperman, 1975). 

Pain: 

Note the major impact that pain can have in causing or worsening postoperative complications. Studies 

have shown that up to 75 percent of postsurgical patients are undertreated for their pain (Frost, 1992). Of 

course, pain in the postoperative state may be difficult to evaluate. If the patient is not fully conscious and 

verbal, it may be manifested by more subtle signs, such as agitation, or hypoventilation secondary to 

splinting of the chest or abdomen. 

H. Assess and Document Pain 

OBJECTIVE 

Evaluate and document postoperative pain as a guide to intervention. 


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ANNOTATION 

In order to accomplish adequate pain control, it is necessary to assess pain on a regular schedule as well as 

following any new pain control intervention. 

• Assess pain intensity using a 0 to 10 numeric rating scale 

• Ask patient to describe the pain (quality, duration and onset) 

• Determine pain location from patient’s report 

• Document intensity, quality and location 

• As time permits and as indicated by patient’s condition, perform a more comprehensive pain 

assessment including description of behavior and impact 

• Assess adverse effects associated with inadequate or intolerable interventions ( sedation, 

inadequate respiration, nausea, vomiting, pruritis, numbness and weakness) 

DISCUSSION 

The initial postoperative assessment of pain evaluates the effectiveness of the pain management that 

occurred intraoperatively and establishes a new baseline for continuing pain management. Systematic pain 

assessment should occur at regular intervals. 

The important domains included in the assessment of pain are: 

• Pain attributes (Intensity, onset, duration, location and description ) 

• Behavior manifestation of pain 

• Impact of pain 

• Current and past treatments for pain 

• Patients’ expectations for pain relief 

The extent and nature of pain assessment will depend on several factors including time available, medical 

status of the patient, and whether the surgery is elective or emergent. 

Detailed instructions, including examples of specific questions and assessment measures, are included in 

the “Pain Assessment” section. 

I. Determine Pain Management Treatment Plan or Modify Preoperative Plan If Indicated 

OBJECTIVE 

Provide safe, effective, and timely pain control. 

ANNOTATION 

Pain management is a complicated, multimodal process. To obtain adequate pain control, a systematic 

comprehensive treatment plan should be established. The treatment plan should be collaborative in nature 

and approved by the patient. The plan should be developed and documented as early in the perioperative 

course as possible. 

The documented plan should address the following: 

• Education 

• Choice of treatment options: 

- Pharmacologic (includes route and dose) 

- Cognitive intervention 

- Physical intervention 

• Discharge plan 


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Information regarding the components of the plan is included in this guideline in several sections: 

• Treatment Options—select the appropriate treatment using the Summary: “Site-specific Pain 

Management” 

• Type of Surgery—discussion of the evidence-based recommendation for the specific type of 

surgery 

• Patient Education—general education for the patient and those taking care of the patient 

• Specific Pharmacologic and Non-Pharmacologic Therapy—specific information regarding route 

and dosage for the specific intervention 

J. Significant Pain Not Explained by Surgical Trauma? Significant Pain Consistent with Surgical 

Trauma? 

OBJECTIVE 

Identify patients who may have a significant complication and need surgical re-evaluation. 

ANNOTATION 

After the initial pain assessment, and before initiating the postoperative treatment plan, the clinician needs 

to determine if the pain is consistent with the recent surgical trauma. 

Questions the provider should consider include: 

• Is the pain level that which would typically be expected after a particular operation? Pain 

experience is individualized and dependent on a number of factors (see the “Site-specific Pain 

Management” section for discussion of typical expected pain). 

• Is the location of the pain appropriate for this operation? 

• Are measures that are normally used to control pain after this operation failing to provide relief? 

The clinician should have a low threshold for consultation/evaluation. If the answers indicate a potential 

significant complication or an atypical postoperative course, then consultation is warranted. 

K. Implement Pain Management Treatment Plan: Initiate Postoperative Analgesia 

Please refer to the Summary Table in the section “Site-specific Pain Management” and the “Options for 

Postoperative Pain Management” section. 

L. Provide Specific Patient and Family Education Regarding the Intervention 

OBJECTIVE 

Provide the patient with education about treatment interventions that promote postprocedural comfort. 

ANNOTATION 

Information to be included in pain education postoperatively should address the following: 

Expectations: 

• Expectation that pain can be controlled following surgery 

• Goals for pain relief 


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Assessment: 

• Ways of assisting in the measurement of pain 

• What patients should report regarding pain and its treatment 

Postoperative plan: 

• Postoperative pain management plan (i.e., specific information about the interventions) 

• Importance of patient involvement in plan (e.g., controlling patient controlled analgesia) 


• How quickly the pain intervention should work 

• When to ask for pain medication 

• Patient concerns about the intervention (e.g., side effects, addiction, complications) 

• Non-drug measures for pain relief (explain those applicable) 

- Physical modalities 

- Cognitive modalities 

One of the primary concerns patients have in the preoperative setting is postoperative pain and discomfort. 

DISCUSSION 

In the immediate postoperative period, uncontrolled pain is a major concern and focus that increases a 

patient’s anxiety. Preoperative concerns about the outcome of the surgery may interfere with the patient’s 

learning about postoperative care. It is therefore important to simply reinforce basic pain management 

principles to help the patient better cope with the pain during this period (Moore and Estey, 1999). 

See the “Education for Pain Management” section for specifics on postoperative pain education material. 



1 Reinforcing pain management principles 

helps the patient cope with postoperative 

pain. 

Moore and Estey, 1999 III B 


M. Did the Intervention Produce Adequate and Tolerable Pain Relief? 

OBJECTIVE 

Determine whether the patient had an adequate response to interventions provided for pain relief. 

ANNOTATION 

Initial pain assessment should include the patient’s goal for pain relief measured as an intensity score (e.g., 

0-10 scale) and function (e.g., what pain rating would be acceptable or satisfactory to him or her, 

considering the activities required for recovery or for maintaining a satisfactory quality of life?). Efficacy 

of pain relief should focus on the location of pain for which the patient received analgesia. If pain is 

located at another site, a complete initial pain assessment should be completed for that different site. 

Adequacy of pain relief is then measured by the following: 

1. Met patient’s goal for pain relief, which included current pain intensity (e.g.,

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2. Pain control at a level that allows the patient to perform the functional requirements necessary for 

recovery (activity) 

3. Duration of pain relief (e.g., did analgesia last between doses) 

4. Patient satisfaction with pain relief 

Possible function (activity/quality of life) from which to select appropriate measure of postoperative 

functioning: 

1. Interference with the ability to cough and deep breathe 

2. Interference with the ability to ambulate 

3. Interference with mood 

4. Interference with sleep 

5. Interference with activities of daily living 

6. Interference with ability to work (include work inside and outside the home) 

7. Interference with relations with other people (interactions) 

8. Interference with enjoyment of life 

DISCUSSION 

The findings of several studies of different cultures have found that, on a 0–10 pain rating scale, pain 

ratings of 5 or more interfere significantly with daily functions (Cleeland, 1984; Cleeland et al., 1994; 

Serlin et al., 1995). Further research suggests that 4, rather than 5, is the point at which pain significantly 

interferes with function. The results of using the Brief Pain Inventory to assess 111 patients with pain and 

advanced cancer showed that, on a 0-10 scale, pain ratings of 4 or greater interfered markedly with activity, 

and interference with enjoyment increased markedly between scores of 6 and 7 (Tycross et al., 1996). This 

study and others, combined with clinical experience, has led many clinicians to the conclusion that a pain 

rating greater than 3 signals the need to revise the pain treatment plan with higher doses of analgesics or 

different medications and other interventions (Cleeland & Syrjala, 1992; Syrjala, 1993). 

One practice implication of these studies is that, when patients and staff are determining the 

comfort/function goal, pain-rating goals greater than 3 should be avoided. Thus, pain ratings of 4 or more 

are not appropriate unless they are temporary or intermediary goals. In other words, for a patient with a 

pain rating of 10, achieving a pain rating of 5 within 8 hours might be a way to make progress toward a 

lower pain rating, such as a 3 within the next 24 hours. Achieving a pain rating of 5 may be appropriate for 

a brief procedure. However, patients who set ongoing goals greater than 3 need to be reminded that 

recovery or quality of life requires that they easily perform certain activities. Emphasize to the patient that 

satisfactory pain relief is a level of pain that is noticeable but not bothersome. Also, explain that a pain 

rating equal to or less than the goal should be maintained as much of the time as possible. Once again, be 

specific about the activities that accompany the pain rating goal. Ask the patient what pain rating would 

make it easy to sleep, eat, or perform other physical activities. 

Not only does setting a comfort/function goal help the entire team, including the patient and significant 

others, know what the pain treatment plan should achieve, but it also helps the patient see how pain relief 

contributes to recovery or improves the quality of life. By setting pain relief goals that correspond to 

function, patients learn that pain relief helps them recover faster from surgery. The patient’s 

comfort/function goal should be visible on all records where pain ratings are recorded, such as a bedside 

flow sheet. Whether the goal has been achieved or not should also be routinely included at change-of-shift 

report, perhaps as the fifth vital sign along with other vital signs (McCaffery, 1999). 



1 Pain ratings of 4 or greater interfered Cleeland & Syrjala, 1992 B II 

markedly with activity. 



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N. Change Drug, Interval, Dose, Route, Modality; Add Adjuvant or Treat Side Effects 

OBJECTIVE 

Modify treatment to achieve effective pain control with minimal harm and side effects. 

ANNOTATION 

Adverse effects associated with inadequate and or intolerable interventions for pain management are 

provided in Table 1 and described below: 

Increased Pain 

Reports of increased pain require pain assessments to ensure that no untoward events have occurred (see 

“Pain Assessment” section). In addition, the assessment will direct the therapy and alternatives selected. 

Nausea/Vomiting 

• Evaluation of postoperative nausea is to ensure stable vital signs and adequate control of pain. 

• Unfortunately, opioids stimulate nausea and may require treatment (Cohen et al., 1992; Wang, 

1996; Gan et al., 1997; Wang et al., 1998; Chung et al., 1999) or alteration of pain therapy to 

allow the patient to be nausea free with pain control. 

• Because of high incidence of nausea, prophylactic antiemetic therapy is often given (Chen et al., 

1996; Pitkanen et al., 1997; Helmy, 1999; Gan et al., 1997). 

• The choice of antinausea agent is driven by patient factors and prior antinausea therapy. For 

example, if a dopamine antagonist was given for nausea earlier, the addition of a serotonin 

antagonist may be more helpful than a second dopamine antagonist. 

Lethargy/Sedation/Respiratory Depression 

• Evaluation is paramount to treatment of sedation. 

• Respiratory depression secondary to opiates is preceded by lethargy and sedation; treatment is the 

same for this side effect. 

• After causes of sedation other than analgesics have been addressed, adjusting the selected pain 

therapy is required (Kenady et al., 1992; Eriksson-Mjoberg et al., 1997; Passchier et al., 1993). 

• If significant overdose of analgesics is suspected, use of reversal agents is indicated (naloxone 

0.4mg IM/IV). If respiratory depression persists, this dose may need to be repeated and other 

causes considered. 

• If there is no medical emergency, small doses of naloxone (0.04-0.2 mg) are preferred. 

Itching/Pruritis 

• Once allergic reactions have been ruled out, treatment of pruritis in the presence of appropriate 

opioid therapy is with antihistamines and opioid antagonists (Cohen et al., 1992; Gan et al., 1997). 

• With regional analgesia techniques, it may be possible to eliminate the opioid component. 

Numbness/Weakness 

• Numbness is not associated with analgesics other than local anesthetics and the cause should be 

sought. 

• Numbness in the affected area in the presence of regional analgesia should be evaluated (possible 

subarachnoid hematoma, abscess) and the dose adjusted. 

• Weakness can be seen with analgesics usually in conjunction with other signs of relative overdose. 

• Weakness seen with regional techniques should be minimized to allow for ambulation with 

assistance if desired. 

Myoclonus/Seizures 

• Seizure-like activity in the postoperative setting should be evaluated and treated. 


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• Some opioids, meperidine in particular, are associated with seizures and myoclonus. 

• While very high doses of local anesthetics can cause seizures, this is unlikely in the postoperative 

setting unless a large amount is actully given. 

Hallucinations 

• Hallucinations in the postoperative patient can be due to a variety of causes including change in 

surroundings, sleep deprivation and intraoperative medications (H2 blockers, anticholinergics, 

opiates). 

• Evaluations of hallucinations are often decided by “trial and error” techniques. 

Dysphoria 

• Postoperative dysphoria is unsettling to the patient and family and difficult to evaluate. 

Sometimes reassurance can be all that is needed, but it may also require changing of pain 

management techniques. 

• It is more common with mixed opioid agonists/antagonists and antidopaminergic medications. 

Urinary Retention 

• Urinary retention is a common side effect of pharmacologic pain management and is more 

common after neuraxial administration. 

Hypotension 

• Hypotension due to systemic analgesics is rare and is likely due to hypovolemia and loss of 

sympathetic drive with appropriate analgesia. 

• Hypotension from neuraxial opioids alone is unlikely. 

• Hypotension with regional analgesia techniques is common and treated by replenishing fluids and 

altering the local anesthetic dose. 

• Short term therapy can be accomplished with vasopressors until the above can be addressed. 

Table 1: Management of Adverse Effects of Therapies 

SYMPTOM 

In order of 

frequency PO IM/IV PCA 

Route 

REGIONAL 

Increased 

Pain 

Nausea and 

Vomiting 

• Increase dose or potency. 

• Decrease interval. 

• Add adjuvant. 

• Change route or site. 

• Evaluate (check vital signs). 

• Decrease dose. 

• Add anti nausea agent. 

• Change pain agent. 

• Change route. 

EPIDURAL/ 

SPINAL 


• Decrease opioid dose. 

• Add anti nausea agent. 

• Change pain agent. 


OTHERS 

Lethargy/ 

Sedation 

Itching/ 

Pruritis 

• Evaluate to determine etiology. 

• Decrease dose/increase interval. 

• Stop medication. 

• Consider reversal agents (Narcan). 

• Consider allergic reaction. 


• Consider antipruretic medication agent. 

• Change agent. 



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Table 1: Management of Adverse Effects of Therapies (continued) 

SYMPTOM 

In order of 

frequency PO IM/IV PCA 

Route 

REGIONAL 

Numbness/ 

Weakness 

Hypotension 

Urinary 

Retention 





• Change position. 

• Check fluid status. 


• Change dose. 

• Change medication. 





• Evaluate to determine 

etiology. 

• Decrease dose level. 

• Increase interval. 

• Adjust technique. 


EPIDURAL/ 

SPINAL 

OTHERS 

Reevaluate. 

Dysphoria 

• Nonpharmacologic therapy/reassurance. 

• Add adjuvant. 

• Consider change of agent/route. 

Myoclonus 

Hallucinations 




• Adjuvant. 




• Add anti-psychotic. 

• Stop infusion. 

• Re-evaluate. 

• Evaluate to determine. 

etiology. 

• Decrease opioid. 

• Stop infusion. 


Reevaluate. 

Stop agent. 

Reevaluate. 

O. Re-evaluate at Appropriate Intervals 

OBJECTIVE 

Evaluate pain as a guide to further intervention. 

ANNOTATION 

The timing for assessment of the efficacy of pain relief is dependent upon the situation. If the patient is in 

severe pain requiring upward titration of analgesics, pain assessment should be completed frequently (e.g., 

every 15 minutes). In general, pain should be assessed approximately 15-30 minutes after administering 

parenteral medication and 60 minutes after administering oral medication. During the initial 24-hour postoperative 

period, pain should be assessed at least every 2 to 4 hours. If pain is well controlled, the pain 

intensity should be assessed routinely with vital signs. 


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P. Provide Discharge Plan 

OBJECTIVE 

Promote continuity of pain management after discharge. 

ANNOTATION 

Provide the patient and family with a workable, effective and safe pain management program for use at 

home, foster continuity of pain management across the care continuum, and promote understanding of the 

treatment plan. 

1. Discharge planning should begin at admission with an assessment of the home environment and 

support systems. 

2. Pain management at home should be within the capability of the patient, significant others, and 

other home resources. Visiting nurses may serve as a valuable resource if a complex pain 

management plan is required. 

3. The pain management plan should guide patients’ expectations as to the likely time course of their 

pain and how to manage functionality and expected return to premorbid function. 

4. A written pain management plan should be given to the patient. It should include: 

• Specific drugs to be taken 

• Dose and frequency of administration 

• Side effects management 

• Potential drug interactions 

• Methods to improve function while recovering 

• Precautions to follow when taking pain medication (e.g., activity limitations, dietary 

restrictions) 

• Contact person for pain problems and other postoperative concerns 

• Nonpharmacological methods 

5. Potential use of over-the-counter medications and interactions with prescribed medication should 

be addressed. 

6. Follow-up contact by day surgery staff regarding the procedure and pain management (for day 

surgery patients) should be scheduled. 

7. Patients who will be discharged to a location other than home must have a comprehensive pain 

management plan in place and clearly communicated in the transfer orders. 

DISCUSSION 

Early discharge planning ensures continuity of care and pain management. It is important to assess the 

discharge environment to evaluate support for the pain management plan proposed for discharge and 

address the patient’s ability to adhere to treatment procedures. It is desirable that, if possible, the 

effectiveness of a plan of care is evaluated before discharge. 

It is important that discharge teaching include anticipated needs and problems, including possible use of 

over-the-counter medications for pain relief. 



1 Assess the discharge environment to 

evaluate support for the pain management 

plan and address the patient’s ability to 

adhere to treatment procedures. 

Hughes et al., 2000 

Jacobs, 2000 

III 

III 

B 

B 





PAIN ASSESSMENT 

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PAIN ASSESSMENT 

Assessment of pain should include the following domains: 

A. Pain attributes 

B. Behavioral manifestations of pain 

C. Impact of pain 

D. Current and past treatments for pain 

E. Patients’ expectations for pain relief 

The assessment’s comprehensiveness will depend upon: 

• The timing of the assessment (e.g., immediately preoperative, immediately postoperative, routinely 

postoperative, several days following surgery). 

• The amount of time available to perform the assessment (e.g., emergency versus elective surgery, 

routine postoperative pain versus pain identified as a persistent problem). 

• Whether a new pain has developed. 

It is desirable, during initial assessment, to inquire and record patients’ descriptions of their pain, 

aggravating and alleviating factors, perceptions of the impact of pain, current and past treatment(s) for pain, 

and patients’ ratings of acceptable pain relief. For routine pain screening, patients should be asked about 

the severity of their pain and its onset, duration, location and quality (description). 

Time permitting, the assessment should be repeated at regularly planned intervals, when a new pain is 

reported and when any new interventions to control pain are initiated. It is not necessary, however, to ask 

about current and past treatments and patients’ acceptable goals each time the pain is assessed. The use of 

standard methods on a routine basis is highly desirable, time permitting. 

A. Pain Attributes 

Pain Intensity 

Assessment and documentation of pain scores in a systematic and consistent manner is an important 

mechanism for promoting identification of unrelieved pain at the individual patient care level. Availability 

of pain scores will provide an important index for monitoring improvement in the pain management. 

Patients are asked to rate the intensity of their pain (e.g., current, worst, average) using the 0 to 10 Numeric 

Rating Scale (NRS) on which 0 equals no pain while 10 represents the worst possible pain (see Figure 1). 

The number reported by each patient is the pain score and should be documented in the medical record. 

The NRS may be used either verbally or visually. 

When using the NRS for pain, the provider would ask, “On a scale of zero to ten, where zero means no pain 

and ten equals the worst possible pain, what is your current pain level?” 

Figure 1. Numeric Rating Scale (NRS) 

|-----------|----------|-------------|----------|------------|-------------|-----------|------------|-------------|----------| 

0 1 2 3 4 5 6 7 8 9 10 

No 

Pain 

Mild Moderate Severe Worst 

Possible 

Pain 

Self-report measures of pain intensity may not be appropriate for patients with problems communicating 

verbally (e.g., patients with strokes or coma). In these instances, the clinician should rely on behavioral 

observations (e.g., wincing, grimacing) and physiological indices (e.g., increase in respiratory rate or 

significant increases in heart rate or blood pressure). 

Pain Assessment Page 1

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Onset and Duration of Pain 

Onset and duration of pain should be determined by patient self-report or by someone who is familiar with 

the patient and his or her condition. 

Pain Location 

Pain location is important as it may provide useful information to help guide further assessment and 

treatment. Asking patients to indicate on their bodies where they feel pain can help to assess the 

distribution (location) of the pain. It is also useful to employ a standard pain drawing, consisting of a line 

drawing outline of the front and back of a human body (see Figure 2). Patients (or their significant others) 

should be asked to indicate the location of their pain on the drawing by marking or shading in the areas of 

the figure. Pain drawings may be more appropriate during the initial pain assessment, time permitting, 

when pain persists, or when a new pain develops, rather than on a routine basis. 

Figure 2: Pain Drawing (Margolis et al., 1986) 

A coding system based on a grid of regions has been established (Margolis et al., 1986). This system may 

be useful in detecting changes in multiple areas over time. 

Pain Description 

Patients should be asked to describe their pain. When time permits, the use of a standard form, such as the 

short form of the McGill Pain Questionnaire (SF-MPQ) (Melzack, 1987), may be helpful as it provides 

patients with a list of frequently endorsed pain descriptors. The short form consists of 15 representative 

adjectival descriptors selected from the longer McGill Pain Questionnaire (Melzack, 1975). The 

descriptors were selected on the basis of their frequency of endorsements by patients with a variety of 


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acute, intermittent, and chronic pain syndromes (see Figure 3). Descriptors 1 to 11 represent the sensory 

dimension of pain and 12 to 15 represent the affective dimension. 

Figure 3: McGill Pain Questionnaire – SF-MPQ (Melzack, 1987) 

Description NONE MILD MODERATE SEVERE 

Score 0 1 2 3 

1 Throbbing 

2 Shooting 

3 Stabbing 

4 Sharp 

5 Cramping 

6 Gnawing 

7 Hot/Burning 

8 Aching 

9 Heavy 

10 Tender 

11 Splitting 

12 Tiring-Exhausting 

13 Sickening 

14 Fearful 

15 Punishing-Cruel 

Scoring: 

• Each item should be scored: 0 = none, 1 = mild, 2 = moderate, and 3 = severe. 

• Mean score of “sensory pain"=sum of scores for items 1 to 11, divided by 11. 

• Mean score for “affective pain"=sum of scores for items 12 to 15, divided by 4. 

• Mean overall pain score obtained by the sum of scores for all 15 items, divided by 15. 

The MPQ may not be appropriate for use with all patients (e.g., patients unable to communicate). Someone 

who is familiar with the patient or the operative procedure may be used as a proxy, but with caution, as the 

subjective nature of pain makes it difficult for anyone to describe someone else’s pain. 

Factors that Alleviate/Exacerbate Pain 

Patients (or significant others) should be asked to list factors that alleviate their pain (“What kinds of things 

make your pain feel better, e.g., heat, medicine,or rest?”) and what factors exacerbate their pain (What 

kinds of things make your pain worse, e.g., coughing, walking, or sitting?”). Checklists are available to 

assist patients and may be used, time permitting. 

B. Behavioral Manifestations of Pain 

The healthcare professional should not only ask for patients’ self-reports but also observe their behaviors 

for an indication of the severity of the pain and pain impact. The general areas to observe include the 

following: 

• Facial/audible expression of distress (e.g., grimaces, moans, or crying) 

• Ambulation and posture (e.g., movement in a protective or guarded fashion; limping, and frequent 

shifting of position; frequent stops when ambulating; and lying in fetal position) 

• Avoidance of activities (e.g., frequent lying down), avoidance of specific movements and other 

behaviors believed to indicate pain, distress, or suffering (e.g., wringing hands, using a cane or 

wearing a cervical collar) 

The nature, number, and frequency of these behaviors should be recorded when possible. 


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C. Impact of Pain 

The 0 to 10 NRS can be used to assess the impact of the pain with the appropriate anchors (0=Does not 

interfere; 10=Completely interferes). Patients (or significant others) can be asked to rate how much pain 

affects or interferes with their general activity, sleep, ability to walk, interactions with other people, and 

personal care (e.g., washing and dressing). 

The 0 to 10 NRS can also be adapted to assess the patients’ moods. The two most important areas are 

anxiety and depression and may be assessed by using the appropriate anchor terms: 0=Extremely 

worried/anxious/upset; 10=Not at all worried/anxious/upset; 0=Extremely depressed; 10=Not at all 

depressed. There are a number of other measures available to assess patients’ moods (Bradley & 

McKendree, 2000). 

D. Current and Past Treatments for Pain 

Patients (or significant others if a patient is unable to communicate) should be asked what pain 

management methods (e.g., pharmacological or non-pharamcological) have been used to treat their current 

and past pain and how effective these were for each pain event, using the 0 to 10 NRS. 

E. Patients’ Expectations for Pain Relief 

When possible, the patient’s (and or significant other’s) goal for, or acceptability of, pain control should be 

rated using the 0 to 10 NRS defining the anchors as: 0=Absolutely no pain; and 10=Worst pain I can 

imagine. 

Satisfaction with pain control should be assessed by asking patients (or significant others) to rate their 

satisfaction with their current and past pain control. The 0 to 10 NRS can be used to assess patient 

satisfaction, defining the anchors as: 0=Completely unsatisfied; and 10=Completely satisfied. 

DISCUSSION 

For pain evaluation, the patient should be asked about A through C and E above and observed for any painrelated 

behaviors (B above). Many clinicians and investigators have recommended the use of visual analog 

scales (VAS) to assess pain intensity. Several studies have reported that patients (especially older patients) 

have difficulty understanding the appropriate use of these scales (Jensen et al., 1986; Jensen et al., 1989; 

Jensen et al., 1992). The advantage of the VAS scale is the almost infinite number of intensity ratings. 

Such a large range will permit identification of very small changes. This may be important for research; 

however, it is not essential in the clinical situation. In addition to the difficulty patients have in using the 

VAS, it is cumbersome for clinical use as it requires someone to measure the very small units using a ruler. 

There are several devices available that can be used to assist the evaluator in measuring VAS scores; 

however, there does not seem to be sufficient need to use VAS in the clinical context. The numeric rating 

scale is easy to administer and to score, demonstrates high compliance rates, and has been shown to have 

good consistency over time (test-retest reliability). 

Self-report measures of pain intensity may not be appropriate for patients with problems communicating 

verbally (e.g., patients with strokes or coma). Other methods are available to assess pain in these patients 

(Hadjistavropoulos et al., 2000). 

The presence of pain affects multiple areas of patients’ functioning and is not always directly correlated 

with pain intensity. It is important to assess not only pain description and ratings of pain intensity, but also 

patients’ perceptions of how pain affects important areas of physical functioning, including the ability to 

engage in routine daily activities, sleep, interactions with others, and mood (Turk & Okifuji, 1999). 


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There are a number of measures designed to assess the impact of pain on functional activities; however, 

many of these are specific to the location of the pain (e.g., back pain). Some general measures also exist, 

most notably the SF-36 (Ware & Sherbourne, 1992). However, these measures tend to be quite long and 

may place too heavy a burden on patients in the preoperative setting. Brief measures of functional 

activities have been shown to be useful and proxy measures for more extensive and more specific activity 

measures (Daut & Cleeland, 1982). 

Although there are a large number of extensive self-reports and interviews designed to assess the role of 

emotional factors and the present mood state of patients (Bradley & McKendree-Smith 2000 in press), such 

extensive measures may not be appropriate as an initial assessment. Self-report on a relatively few items 

assessing mood have been shown to be highly correlated with more extensive questionnaires (Daut & 

Cleeland, 1982; Kerns et al., 1985). These relatively brief measures of patient mood have been shown to 

have good reliability (i.e., internal consistency, stability), validity, and sensitivity to change. 




SITE-SPECIFIC PAIN MANAGEMENT 

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Version 1.2 VHA/DoD Clinical Practice Guideline for the 


Summary Table: Site-specific Pain Management Interventions 

Pharmacologic Therapy (Route) Non-Pharmacologic 

Type of surgery by body region PO IM IV Epidural Intrathecal IV PCA Regional Physical Cognitive Comments 

1. Head and neck 

Ophthalmic OP, NS OP, NS OP, NS -- -- RARELY LA C X If there is risk of or actual bleeding, avoid NS* 

Craniotomy OP, NS OP, NS OP, NS -- -- OP LA If there is risk of or actual bleeding, avoid NS* 

If there is renal hypoperfusion, avoid all NS 

Radical neck OP, NS OP, NS OP, NS -- -- OP LA X 

Oral-maxillofacial OP, NS, CS OP, NS, CS OP, NS, CS -- -- OP LA C, I X 

2. Thorax-noncardiac 

Thoracotomy OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, T X If there is riskof or actual bleeding, avoid NS* 


Mastectomy OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, T X 

Thoracoscopy OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, T X 

3. Thorax-Cardiac 

CABG OP, NS OP, NS OP, NS RARELY OP OP RARELY If there is risk of or actual bleeding, avoid NS* 


MID-CAB OP, NS OP, NS OP, NS RARELY OP OP LA X If there is risk of or actual bleeding, avoid NS* 


4. Upper abdomen 

Laparotomy OP, NS OP, NS OP, NS OP, LA OP, LA OP LA E, T X Opioids may impair bowel function 

If there is risk of or actual bleeding, avoid NS* 


Laparoscopic cholecystectomy OP, NS OP, NS OP, NS RARELY RARELY OP LA E, T X Opioids may cause biliary spasm 

Nephrectomy OP, NS OP, NS OP, NS OP LA OP, LA OP LA E, T X 

5. Lower abdomen/pelvis 

Hysterectomy OP, NS OP, NS OP, NS OP, LA OP, LA OP LA E, X Opioids may impair bowel function 

Radical prostatectomy OP, NS OP, NS OP, NS OP, LA OP, LA OP -- E X Opioids may impair bowel function 

If there is risk of or actual bleeding, avoid NS* 


Hernia OP, NS OP, NS OP, NS RARELY OP RARELY LA C, X 

7. Back/Spinal 

Laminectomy OP, NS OP, NS OP, NS RARELY RARELY OP -- C, E X 

Spinal fusion OP OP OP RARELY RARELY OP -- E I X Use of NS may be associated with nonunion 

6. Extremities 

Vascular OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, E X If there is risk of or actual bleeding, avoid NS* 


Total hip replacement OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, E, T X Use of NS is controversial 

Total knee replacement OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, E, T X Use of NS is controversial 

Knee arthroscopy / 

OP, NS OP, NS OP, NS RARELY OP OP LA C, E, T X 

Arthroscopic joint repair 

Amputation OP, NS OP, NS OP, NS OP, LA OP, LA OP LA C, E, T X 

Shoulder OP, NS OP, NS OP, NS -- -- OP LA C, E, I, T X 

OP = Opioids; NS = NSAIDs; CS = Corticosteroid; LA = Local Anesthetics; C = Cold; E = Exercise; I = Immobilization; T = TENS; X = Use of cognitive therapy is patient-dependent rather than procedure-dependent 

Indications for Use: Bold/Red/Shaded: Preferred based on evidence (QE=1; R=A); Italicized/Blue: Common usage based on consensus (QE=III); Plain Text: Possible Use; * = Bleeding is not contraindication for COX-2 

Site-specific Pain Management Page 1



How to Use this Table 

1. Select operation from column 1, “Type of surgery by body region”. If your operation is not exactly listed pick one that 

is close to it. For example, for a patient having a colon operation the appropriate choice would be “laparotomy”. 

2. Examine options on horizontal axis. 

Factors to consider: 

• Evidence rating—i.e., is it the best available? 

• Patient factors 

- patient motivation or desire 

- medical conditions (example: anticoagulation) 

• Institutional factors 

- Who will implement choice? 

- Is specialized equipment available? 

- Are the appropriate practitioners available (Example: Is physical therapy available for placement of TENS) 

3. Additional considerations and suggestions can be found under the pharmacologic, non-pharmacologic and intervention 

sections. 


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HEAD AND NECK SURGERY 

Type of Pain: 

Operations involving the head and neck region are varied and result in both nociceptive and neuropathic 

pain (Sharf et al., 1977). 

Severity/Duration: 

Although the severity range for pain following head and neck surgery extends from mild to severe, most 

patients have mild to moderate pain of several days' duration (Bost et al., 1999; Mom et al.,1996; Cannon, 

1990). 


Oral agents are commonly used with or without adjuvant agents. Intraspinal medications are rarely 

indicated. Some larger procedures may preclude use of tablets or capsules. 

Considerations: 

• Pain relief regimens following neurosurgical procedures must not interfere with the ability to 

monitor neurologic status (MacKersie, 1993). 

• Oropharyngeal and neck operations can interfere with swallowing and may preclude the use of 

oral agents. 

• Operations involving the oropharynx and the neck may cause severe life-threatening airway 

compromise. As a result, postoperative analgesic techniques must be carefully selected to 

minimize the risk. 



1 Pain relief regimens following neurosurgical 

procedures must not interfere with the ability to 

monitor neurologic status. 

MacKersie, 1993 III-3 B 



Version 1.2 




Ophthalmic Surgery 


A wide variety of eye operations involve little nociceptive pain. The notable exceptions are enucleation 

and retinal surgeries, which produce pain that is both nociceptive and neuropathic (Fezza et al., 1999). 


Pain following ophthalmic surgery is mild to severe in intensity and lasts several days. Phantom eye pain 

of mild to severe intensity may develop following enucleation and last for months to years (Nicolodi et al., 

1997). 


Oral pain medications are a commonly used technique. Regional anesthetics used during surgery provide 

better analgesia in the immediate postoperative period (Calenda et al., 1999; Lai et al., 1999; Williams et 

al., 1995; Shende et al., 2000). Retinal operations or enucleations may be more painful and require more 

analgesia. 


Nausea and vomiting following surgery may be detrimental to the surgical repair. Therefore, non-opiate 

pain medications postoperatively or regional anesthesia intraoperatively are preferred for mild to moderate 

pain (Williams et al., 1995; Shende et al., 2000). 



1 Regional anesthetics used during surgery 

provide better analgesia in the immediate postoperative 

period. 

Calenda et al., 1999 

Lai et al., 1999 

Williams et al., 1995 

Shende et al., 2000 

II-2 

II-2 

II-2 

I 

A 

B 

B 

A 

2 Nausea and vomiting may be detrimental to 

surgical repair. Therefore, non-opiate pain 

medications postoperatively or regional 

anesthesia intraoperatively are preferred. 

Williams et al., 1995 

Shende et al., 2000 

II-2 

I 

B 

A 



Version 1.2 




Craniotomies 


Craniotomies are generally thought to be less painful than other operations (Atkinson et al., 1993; Conway, 

1984; Dunbar et al., 1999; Bonica, 1990) except for frontal craniotomies (Dunbar & Lam, 1999). 

However, both of these assumptions have recently been challenged (DeBenedittis et al., 1996; Quiney & 

Cooper., 1996) and supported (Dunbar & Lam, 1999). Suffice it to say that, while craniotomy pain may be 

less severe than other operations, there is a growing consensus that it remains undertreated in the acute 

recovery phase for at least a minority of patients (Dunbar & Lam, 1999; Quiney et al., 1996; DeBenedittis 

et al., 1996; Stoneham & Walters, 1995). The pain that results is typically nociceptive in nature, and is 

secondary to the surgical incision and reflection of the muscle underlying the scalp (Quiney et al., 1996; 

DeBenedittis et al., 1996), but not of the brain tissue itself (Bonica, 1990; DeBenedittis et al., 1996). 


Craniotomy pain is mild to severe and decreases rapidly after the first 24 hours (DeBenedittis et al., 1996). 


Postoperative pain control recommendations have been very conservative (Mackersie, 1993), with 

intramuscular codeine phosphate used as the most common postoperative analgesic (Stoneham & Walters, 

1995). This approach has generally been accepted because of concerns about respiratory depression and 

altered mental status in postoperative craniotomy patients (Mackersie, 1993). Codeine may be the 

preferred narcotic analgesic because of its lesser effects on brain/blood flow. It has been shown to be 

superior to tramadol as a post-operative analgesic and not significantly different from IV PCA morphine 

(Stoneham et al., 1996). NSAIDs may be contraindicated in some settings due to concerns regarding 

intracranial bleeding (Palmer et al., 1994). Incisional bupivicaine is helpful in the immediate postoperative 

phase to achieve pain control (Bloomfield et al., 1998). 


Analgesia needs to be balanced with the requirement for appropriate neurologic monitoring. 



1 While pain may be less severe than other 

operations, there is a growing consensus that it 

remains undertreated. 

Dunbar & Lam, 1999 

Quiney et al., 1996 

DeBenedittis et al., 1996 

Stoneham & Walters, 1995 

II-3 

II-2 

II-2 

I 

B 

B 

B 

A 

2 Post-operative pain control recommendations have 

been very conservative, with intramuscular codeine 

phosphate used as the most common postoperative 

analgesic. 

MacKersie, 1993 

Stoneham & Walters, 1995 

III 

I 

C 

A 



Version 1.2 




3 Codeine has been shown to be superior to tramadol 

as a postoperative analgesic and not significantly 

different from IV PCA morphine. 

Stoneham & Walters, 1995 I A 

4 NASIDs may be contraindicated in some settings 

due to concerns regarding intracranial bleeding. 

5 Incisional bupivicaine is helpful in the immediate 

postoperative phase to achieve pain control. 

Palmer et al., 1994 II-2 A 

Bloomfield et al., 1998 I A 



Version 1.2 




Radical Neck Surgery 


Radical neck surgery may produce both nociceptive and neuropathic pain (Sharf et al., 1997). 


Pain from radical neck surgery is moderate to severe in intensity lasting days to years (Bost et al., 1999; 

Mom et al., 1996; Cannon, 1990; Chaplin & Morton, 1999; Sist et al., 1999). 


Pain from radical neck surgery is typically controlled with IM, IV, or IV PCA opiates due to frequent 

limitations in oral intake (Bost et al., 1999; Mom et al., 1996). Intraspinal medications are almost never 

used for postoperative pain control in this setting (Tobias et al., 1990). 


The choice of analgesia must consider the potential for airway compromise in patients without 

tracheostomy. 



1 Pain from radical neck surgery is typically 

controlled with IM, IV, or IV PCA opiates due 

to frequent limitations in oral intake. 

Bost et al., 1999 

Mom et al., 1996 

II-2 

II-3 

B 

A 

2 Intraspinal medications are almost never used 

for postoperative pain control in this setting. 

Tobias et al., 1990 III B 



Version 1.2 




Oral-Maxillofacial 


Oral and maxillofacial procedures include a wide range of operations that result in both nociceptive and 

neuropathic pain. 


Pain from oral and maxillofacial procedures ranges from mild to severe. Outpatient procedures are 

associated with pain of short duration (1-3 days). 


• Regional anesthesia is commonly provided intraoperatively by the surgeons to reduce both 

intraprocedural and early postprocedural pain (Robiony et al., 1999; Nicodemus et al., 1991). Oral 

opiates and nonsteroidal analgesia usually follow this. If the oral route is not available, effective 

pain control can be obtained using IM or IV opiate pain medications or IV or IM nonsteroidals. 

• Extensive maxillofacial procedures, such as LE FORTE I maxillary osteotomies, may result in 

severe postoperative pain requiring IV or IM narcotics. In the setting of Internal Mandibular (IM) 

Fixation, opiates may be used in elixir form. 


• Oral route may be unavailable. 

• Potential airway compromise. 



1 Regional anesthesia is commonly provided 

intraoperatively by the surgeons to reduce both 

intraprocedural and early postprocedural pain. 

Robiony et al., 1999 

Nicodemus et al., 1991 

II-3 

I 

B 

A 



Version 1.2 



THORAX (NON-CARDIAC) SURGERY 

Operative sites within the thorax include the heart, esophagus, and lungs, and somatically innervated 

structures such as the ribs, superficial chest wall, and breast. Procedures include thoracotomy, transhiatal 

esophagectomy, pneumonectomy, thoracoscopy and mastectomy. 


Thoracic (non-cardiac) surgery produces nociceptive and neuropathic pain. 


Thoracic (non-cardiac) surgery produces pain that is moderate to severe in intensity lasting days to weeks. 

Patients may develop chronic post-thoracotomy or post-mastectomy pain syndromes lasting months to 

years (Katz et al., 1996). 


There are a wide variety of analgesic techniques that have been used to provide pain control following 

surgical procedures involving the chest. These include the following: 

• Epidural analgesia 

• Intrathecal analgesia 

• Paravertebral nerve blocks 

• Intercostal nerve blocks 

• Oral, intravenous, intramuscular, and IV PCA opioids 

• Transcutaneous Electrical Nerve Stimulation (TENS) 

• NSAIDs 

• Acetaminophen 

• Mixed agonist-antagonist opioid analgesics 


• Preexisting disease of thoracic organs (e.g., chronic obstructive pulmonary disease) or prior 

medical treatment (e.g., chemotherapy) is common. The presence of significant preoperative 

medical disease may contribute to postoperative morbidity through a variety of mechanisms, such 

as decreased pulmonary reserve or malnutrition. 

• Assessing the optimal time for switching the care of patients with epidural catheters to oral 

analgesics is best accomplished by a specially trained team. 

• Transition from intravenous PCA to oral opiates should be accomplished when the patient’s bowel 

function recovers. If adequate opioid analgesia yields undesired side effects or the pain is not 

severe (e.g., when chest tubes are no longer in place), the patient can switch directly from epidural 

analgesia to oral analgesics using either opioids alone or a combination of opioid and 

acetaminophen or an NSAID. 


Version 1.2 




Thoracotomy 


Thoracotomy produces nociceptive and neuropathic pain that is aggravated by respiration and coughing. 

Pain may be further exacerbated by the presence of chest tubes and drains. 


Thoracotomy pain is generally moderate to severe, lasting weeks. Patients may develop post-thoracotomy 

pain syndromes lasting months to years. 


• There is good evidence that aggressive pain control in the form of epidural analgesia or neural 

blockade with local anesthesia following thoracic surgery improves pulmonary function, reduces 

morbidity, and reduces the length of stay in intensive care. 

• Effective postoperative pain control may be achieved by delivering an opioid or a combination of 

an opioid and local anesthetic into the thoracic epidural space (Mahon et al., 1999; Miguel & 

Hubbell, 1993; Brichon et al., 1994). Mixing a local anesthetic with an opioid produces better and 

more prolonged analgesia, but randomized controlled trials indicate that there is a tendency toward 

more side effects when an opioid is added to a local anesthetic as compared to local anesthetic 

alone (Mahon et al., 1999). The addition of local anesthetics to epidural opioids allows a 

significant reduction in the total opioid required to produce equivalent analgesia (Burgess et al., 

1994). However, reliance on local anesthetics alone to secure postoperative epidural analgesia in 

the thoracic region may be associated with hypotension due to sympathetic blockade. Epidural 

opioids may be delivered via either a lumbar or thoracic approach (Gaeta et al., 1995). Lumbar 

epidural opioids have been used successfully to provide analgesia but are less effective than 

thoracic administration. An example of a coordinated approach to postoperative analgesia 

following thoracic surgery is the placement of an epidural catheter prior to induction of anesthesia. 

This catheter may be used to deliver local anesthetic, either alone or mixed with an opioid for 

intraoperative analgesia. The catheter may then be left in place postoperatively for infusion of an 

analgesic solution containing either a local anesthetic, an opioid, or a combination of the two, 

delivered either as a continuous infusion or patient-controlled epidural analgesia. The patient is 

then switched to patient-controlled analgesia or oral analgesics if the epidural catheter ceases to 

function or is discontinued after several days. 

• There is no significant difference between lumbar and thoracic epidural administration of the 

highly lipid-soluble opioids, fentanyl and sufentanil (Haak-van der Lely et al., 1994; Swenson et 

al., 1994). In addition, there is no significant difference between epidural and intravenous 

administration of these highly lipid-soluble opioids (Baxter et al., 1994; Sandler et al., 1992; 

Guinard et al., 1992). 

• Preoperative initiation of a continuous local anesthetic epidural block has been associated with 

reduced long-term (at 6 months) post-thoracotomy pain (Obata et al., 1999). 

• Paravertebral blocks performed as single shot or continuous techniques are also useful in 

providing postoperative analgesia following thoracic surgical procedures (Carabine et al., 1995). 

Continuous paravertebral blocks provide superior postoperative analgesia when compared to 

single shot techniques (Catala et al., 1996). Continuous paravertebral blocks are capable of 

providing equivalent or superior pain control when compared to epidural analgesia following 

thoracotomy (Richardson et al., 1999). Continuous paravertebral blocks are superior to 

interpleural blocks following thoracotomy (Richardson et al., 1995). 


Version 1.2 



• Direct injection of a local anesthetic alone to block intercostal nerves has been performed as a 

means to provide postoperative analgesia and improve pulmonary function after thoracotomy. 

Since the analgesia from these blocks lasts only 6-12 hours, a single injection rarely suffices for 

the entire postoperative period. More prolonged relief can be obtained by performing 

cryoanalgesic blocks of the intercostal nerves (Bucerius et al., 2000). This may provide pain relief 

for several weeks. The brief duration of intercostal nerve blocks has been treated in some centers 

by administering interpleural local anesthetics. A catheter is placed between the parietal and 

visceral pleura, and a local anesthetic is injected at 4-6 hour intervals or infused continuously to 

produce continuous analgesia across several dermatomes (Barron et al., 1999; Raffin et al., 1994). 

Clinical use of this technique has not found widespread acceptance and it has been out of favor for 

many years (Gaeta et al., 1995; Solomon et al., 1980). 

• Intrathecal administration of opioids has been used successfully to provide postoperative analgesia 

following thoracic surgical procedures. Intrathecal opiates may be used to provide postoperative 

analgesia following thoracotomy. This technique is associated with good analgesia at rest and a 

reduction in the need for opiates delivered via other routes during the first 24 hours. It may also 

be associated with a higher incidence of side effects when compared with epidural opioids or 

epidural local anesthetic and opioid combinations. The addition of intercostal nerve blocks to 

intrathecal opioids does not significantly improve postoperative pain control and has been 

associated with decreased pulmonary function after 24 hours (Liu et al., 1995). 

• Administration of opioids via oral, IV, IM, or IV PCA routes can be an effective means of 

providing primary postoperative pain control or as an adjunct to regional or neuraxial analgesic 

techniques. The use of opioids to reduce postoperative pain after thoracotomy is well-documented. 

Because of potential side effects, clinicians have tried to optimize delivery and closely match the 

dose needed. In this context, IV PCA has resulted in incrementally improved analgesia, increased 

patient satisfaction, and tendency toward improved pulmonary function and earlier recovery or 

discharge. 

• Drains and chest tubes inserted during surgery can cause intense irritation and pain at entry sites or 

deeper. The use of NSAIDs as an adjunct to other postoperative analgesics is beneficial for 

control of nonincisional pain following thoracotomy (Singh et al., 1997). Acetaminophen may be 

used as an adjunctive analgesic if an NSAID is contraindicated. These medications are rarely, if 

ever, sufficient to provide complete pain relief following thoracotomy. 

• The use of TENS may serve as a useful adjuvant following minor thoracic surgical procedures. 


• Pulmonary toilet is very important in ensuring a good outcome, so pain control is of paramount 

importance. Regional analgesic techniques provide better pulmonary toilet than IV PCA (Benzon 

et al., 1993). 

• Opiates should be used cautiously in the setting of severe pulmonary disease due to the potential 

complication of respiratory depression. Therefore, in this group, regional analgesia may be 

strongly preferred (Benzon et al., 1993). 



1 Effective postoperative pain control may be 

achieved by delivering an opioid or a 

combination of opioid and local anesthetic into 

the thoracic epidural space. 

Mahon et al., 1999 

Brichon et al., 1994 

Miguel & Hubbell, 1993 

I 

I 

I 

A 

A 

A 


Version 1.2 




2 Mixing a local anesthetic with an opioid produces 

better analgesia, but RCTs indicate that there is a 

tendency toward more side effects when an 

opioid is added to a local anesthetic as compared 

to local anesthetic alone. 

Mahon et al., 1999 I B 

3 The addition of local anesthetic to epidural opioid 

allows a significant reduction in the total dose of 

opioid required to produce equivalent analgesia. 

4 Epidural opioids (hydrophillil) may be delivered 

via a lumbar or thoracic approach. 

Burgess et al., 1994 I A 

Gaeta et al., 1995 I B 

5 There is no significant difference between lumbar 

and thoracic epidural administration of the highly 

lipid-soluble opioids, fentanyl and sufentanil. 

Swenson et al., 1994 

Haak-van der Lely, 1994 

I 

II-1 

A 

B 

6 There is no significant difference between 

epidural and intravenous administration of the 

highly lipid-soluble opioids. 

Baxter et al., 1994 

Sandler et al., 1992 

Guinard et al., 1992 

I 

I 

I 

B 

A 

A 

7 Pre-operative initiation of continuous local 

anesthetic epidural block has been associated 

with reduced long-term (at 6 months) pain. 

8 Continuous paravertebral blocks are capable of 

providing equivalent or superior pain control 

when compared to epidural analgesia following 

thoracotomy. 

9 Continuous paravertebral blocks are superior to 

interpleural block following thoracotomy. 

10 Direct injection of a local anesthetic alone to 

block intercostal nerves can be used. Analgesia 

only lasts 6-12 hours. More prolonged relief can 

be obtained by performing cryoanalgesic blocks 

of the intercostal nerves. 

Obata et al., 1999 I A 

Catala et al., 1999 I B 

Richardson et al., 1995 II-2 B 

Burcerius et al., 2000 I B 

11 Interpleural local anesthetics can be delivered via 

catheter between the parietal and visceral pleura 

and a local anesthetic injected at 4-6 hour 

intervals or infused continuously to produce 

analgesia… 

…Clinical use of this technique has not found 

widespread acceptance and it has been out of 

favor for many years. 

Barron et al., 1999 

Raffin et al., 1994 

Solomon et al., 2000 

Gaeta et al., 1995 

I 

I 

I 

I 

A 

A 

A 

B 


Version 1.2 




12 The addition of intercostal nerve blocks to 

intrathecal opioids does not significantly improve 

postoperative pain control and has been 

associated with decreased pulmonary function 

after 24 hours. 

Liu et al., 1995 I B 

13 Opioids via oral, IV, IM, or IV PCA can provide 

postoperative pain control or be used as an 

adjunct to regional or neuraxial analgesia. 

VHA/DoD Guideline working 

group 

III 

C 

14 The use of NSAIDs as an adjunct to other 

postoperative analgesics is beneficial for nonincisional 

pain. 

15 Regional analgesic techniques provide better 

pulmonary toilet than IV PCA. 

16 Opiates should be used cautiously in the setting 

of severe pulmonary disease due to the potential 

for respiratory depression. 

Singh et al., 1997 I A 

Benzon et al., 1993 I B 

Benzon et al., 1993 I B 



Version 1.2 




Mastectomy 


Mastectomy produces pain that is both nociceptive and neuropathic in nature. 


Pain from mastectomy is moderate to severe and lasts weeks. In rare instances, patients may develop postmastectomy 

pain syndromes persisting for months to years. 


• Paravertebral or intercostal blocks may be useful in providing postoperative analgesia for up to 24 

hours for either inpatient or outpatient surgical procedures (Atanassoff et al., 1994; Klein et al., 

2000). 

• Thoracic epidural analgesia provides greater pain control and patient satisfaction, but is not 

frequently used because patients are discharged quickly (Yeh et al., 1999). 

• Postoperative oral opioids are preferred because this may be done as an ambulatory surgical 

procedure. 

• For hospitalized patients, an IV PCA is used for the first 24 hours followed by oral agents. 

• NSAIDs may be used for postoperative pain (Chan et al., 1996). 

. 


Patients may develop post-mastectomy pain syndromes involving the intercostal-brachial nerve that is often 

injured or resected during the performance of axillary lymph node dissection. 



1 Paravertebral or intercostal blocks may provide Atanassoff et al., 1994 I A 

postoperative analgesia for up to 24 hours. 

Klein et al., 2000 

I A 

2 Thoracic epidural analgesia provides excellent pain 

control and patient satisfaction. 

Yeh et al., 1999 I A 

3 NSAIDs may be used for postoperative pain. Chan et al., 1996 I A 



Version 1.2 




Thoracoscopy 


Thoracoscopy pain is primarily nociceptive in nature. 


Pain from thoracoscopy is mild to severe and lasts from days to weeks (Kirby et al., 1995; Santambrogio et 

al., 1995). In most patients the pain is mild to moderate. 


• Adequate analgesia can be readily obtained in most patients using oral, IV, IM, or IV PCA 

opiates. 

• Supplemental treatment with NSAIDs or the use of TENS may allow a significant reduction in the 

use of postoperative opiate pain medications (Perttunen et al., 1999). 

• Pain control in the immediate postoperative period may be enhanced by injection of a local 

anesthetic through the thoracoscope at the end of surgery (Lieou et al., 1996), incisional local 

anesthetic infiltration, or paravertebral or intercostal nerve blocks. 

• In patients with extensive operations or poorly controlled pain, the use of epidural analgesia may 

be required. 


Thorascopic procedures result in less postoperative pain and shorter lengths of stay as compared to 

thoracotomy. 



1 Supplemental treatment with NSAIDs or the use of 

TENS may allow a significant reduction in the use of 

postoperative opiate pain medications. 

Perttunen et al., 1999 II-1 A 

2 Pain control in the immediate postoperative period may 

be enhanced by injection of local anesthetic through the 

thoracoscope at the end of surgery. 

Lieou et al., 1996 I A 



Version 1.2 



THORAX (CARDIAC) SURGERY 

Coronary artery bypass grafting (CABG), heart valve repair/replacement, and minimally invasive direct 

coronary artery bypass grafts (mid-CABS). 


Thoracic (cardiac) surgery produces pain that is nociceptive in nature. 


Thoracic (cardiac) surgery produces pain lasting days to weeks. Because somatic nerves are not divided by 

the surgical incision, postoperative pain is usually less than after conventional thoracotomy. In rare 

circumstances, patients may have pain that persists for months to years related to sternal nonunion and 

suture or wire problems. Mid-CAB surgery produces mild to moderate pain lasting days to weeks. 


• Most cardiac operations involve a median sternotomy and anesthetic induction using high doses of 

opioids. 

• The pain of median sternotomy is frequently controlled with IV or IV PCA opiates. This is 

rapidly transitioned to oral opiates alone. 

• Although it has been used successfully, epidural analgesia is uncommon in the setting of median 

sternotomy for cardiac surgery at the present time. 

• Mid-CABs transition to oral medications very rapidly. 


The frequent use of complete anticoagulation during thoracic cardiac surgery has resulted in significant 

concerns regarding the potential for complications associated with the use of epidural analgesia. 


Version 1.2 




Coronary Artery Bypass Graft (CABG) 


CABG produces pain from the sternum and drain sites that is nociceptive in nature. 

Severity/duration: 

Pain from a CABG is moderate to severe and lasts days to weeks. 


• Pain control post-CABG is initially via IV PCA, IM, or IV routes. This rapidly changes to oral 

medication. In the first 24 hours, non-patient dependent routes (i.e. nurse administration) may be 

preferred to IV PCA (Tsang & Brush, 1999; Checketts et al., 1998; Munro et al., 1998; O’Halloran 

& Brown, 1997; Myles et al., 1994). After 24 hours, IV PCA transitioning to oral is preferred 

(Boldt et al., 1998). 

• NSAIDs may be helpful for post-sternotomy pain. 

• Neuraxial analgesia is rarely used but helps pulmonary function (Stenseth et al., 1996). 

• Intrathecal opiates may be helpful in the first 24 hours, but may delay extubation (Chaney et al., 

1999; Chaney et al., 1996; Shroff et al., 1997). 


Because full systemic anticoagulation is necessary, epidural analgesia is rarely used. 


Interventions Source of Evidence QE R 

1 In the first 24 hours, non-patient dependent routes 

may be preferred (i.e., nurse administration). 

Tsang & Brush, 1999 

Checketts et al., 1998 

Munro et al., 1998 

O'Halloran & Brown, 1997 

Myles et al., 1994 

II-2 

I 

I 

I 

I 

A 

B 

A 

A 

A 

2 After 24 hours, IV PCA transitioning to oral is 

preferred. 

3 Neuraxial analgesia is rarely used, but helps 

pulmonary function. 

Boldt et al., 1998 I B 

Stenseth et al., 1996 I B 

4 Intrathecal opiates may be helpful in the first 24 

hours but may delay extubation. 

Chaney et al., 1999 

Chaney et al., 1996 

Shroff et al., 1997 

I 

I 

I 

A 

B 

B 



Version 1.2 




Minimally Invasive Direct Coronary Artery Bypass (MID-CAB) 


Mid-CAB surgery produces pain that is nociceptive and neuropathic in nature. 


Pain from mid-CABs is moderate to severe and lasts days to weeks. 


• Pain control post MID-CAB is initially via IV PCA, IM, or IV routes. This rapidly changes to oral 

medication. 

• NSAIDs may be helpful. 

• Neuraxial analgesia is rarely used (Stenseth et al., 1996). 

• Intrathecal opiates may be helpful in the first 24 hours (Chaney et al., 1999). 

• Intraoperative cryoablation may improve postoperative pain control (Bucerius et al., 2000; Pastor 

et al., 1996). 



1 Intrathecal opiates may be helpful in the Chaney et al., 1999 I A 

first 24 hours. 

2 Neuraxial analgesia is rarely used. Stenseth et al., 1996 I B 

3 Intraoperative cryoablation may improve 

postoperative pain control. 

Bucerius et al., 2000 

Pastor et al., 1996 

II-1 

II-1 

B 

B 



Version 1.2 



UPPER ABDOMINAL SURGERY 

Operative sites in the upper abdomen include the visceral and vascular structures, such as the stomach, 

gallbladder, pancreas, bowel, and aorta. Both somatic and visceral structures generate postoperative pain 

after intra-abdominal procedures such as laparotomy, cholecystectomy, nephrectomy, gastrectomy, gastric 

bypass, pancreatectomy, splenectomy, and abdominal aortic aneurysm repair. 


Upper abdominal surgery results in nociceptive (somatic and visceral) and neuropathic pain. 


Upper abdominal surgery produces pain of mild to severe intensity lasting days to weeks. Laparoscopic 

procedures produce mild to moderate pain lasting several days. Non-laparoscopic procedures, including 

flank incision, clam-shell incision, and midline laparotomy all produce pain of moderate to severe intensity 

lasting days to weeks. 


Many analgesic techniques are used to provide pain control after upper abdominal surgery. The decision to 

use one over another should consider both the expected postoperative pain and the patient’s underlying 

medical condition. Multimodal analgesia using local anesthetic, NSAIDs, and opiates provides improved 

pain control, decreased nausea, and faster discharge following laparoscopic cholecystectomy 

(Michaloliakou et al., 1996). Adequate pain relief following upper abdominal surgery helps to reduce 

postoperative respiratory complications (Vassilakopoulos et al., 2000). Interventions include: 

• IV/IM Opiates 

Adequate analgesia at rest can be readily obtained with IV, IM, or IV PCA opiates (Wheatley, 1992; 

Passchier et al., 1993). Patients receiving IV PCA opiates tend to have better pain relief and to use more 

morphine than those limited to IM morphine on demand. Due to the potential for side effects, clinicians 

have tried to optimize delivery and match the dose to that required by the patient. In this context, IV PCA 

has resulted in incrementally improved analgesia, increased patient satisfaction, and a tendency toward 

improved pulmonary function, bowel function, and earlier discharge. These pain treatments frequently do 

not provide good pain control during movements, such as coughing, deep breathing, or ambulation. This 

route may serve as a bridge between interventions, e.g., a patient coming off of epidural analgesia but not 

yet ready for oral analgesics. 

• Epidural Analgesia 

Epidural analgesia, incorporating the use of local anesthetics or local anesthetic with opiates (Wiebalck et 

al., 1997; Schug et al., 1995) provides better pain control during activity while allowing a reduction in the 

total dose of opiates and fewer side effects (Mulroy et al., 1996; George et al., 1994). The net effect of this 

combination allows improved pain control at rest and with movement, improved pulmonary function, 

decreased side effects, and faster recovery of bowel function (Mann et al., 2000; Liu et al., 1995). Epidural 

analgesia after upper abdominal surgery has also been associated with less postoperative myocardial 

ischemia (deLeon-Casasola et al., 1995). In order to produce optimal analgesia, the thoracic epidural route 

should be used for upper abdominal surgery, especially if local anesthetics are to be used (Wiebalck et al. 

1997; Chisakuta et al., 1995; George et al., 1994). Patient-controlled epidural analgesia (PCEA) is another 

effective intervention in this population (Komatsu et al., 1998). Epidural analgesia is the treatment of 

choice for pain following upper abdominal surgery. Once bowel function has recovered, patients can 

readily be switched to oral opiates and NSAIDs. 

• Intrathecal Opioids 

Intrathecal administration of opioids has been used successfully to provide analgesia following upper 

abdominal surgery. This technique is associated with good analgesia at rest for up to 24 hours. A 

drawback is the inability to re-dose without repeating the injection. Therefore, the effects are time-limited. 

Intrathecal opioids may be associated with a higher incidence of side effects when compared to the epidural 

route. 


Version 1.2 



• Intercostal Nerve Block 

The use of intercostal nerve blockade in combination with opiates has been shown to be more effective than 

opiates alone after subcostal incisions. They are not effective after midline laparotomy incisions (Engberg 

et al., 1985). However, given the limited duration of their effects (6-12 hours) and their need to be 

repeated, various authors have suggested means of prolonging the duration of the block. These 

recommendations have included cryoanalgesia and phenol in combination with local anesthetic (Maidatsi et 

al., 1998). Some centers have used interpleural catheters to provide prolonged intercostal neural blockade 

after upper abdominal surgery. This technique has not found widespread use and is not recommended as an 

initial therapy. 

• Local Anesthetic Injection into Wound/Incision 

Infiltration of the incision and/or wound by the surgeon with local anesthesia is a technique that has been 

used widely for many years. Preoperative infiltration of the wound with local anesthetic in addition to 

postoperative analgesia with epidural bupivicaine and morphine produced improved analgesia during 

mobilization and reduced the need for supplemental intramuscular morphine (Bartholdy et al., 1994). 

• NSAIDs 

Ketorolac has been shown to be a valuable adjuvant in the treatment of pain after laparoscopic upper 

abdominal surgery and facilitates the transition to oral pain medications (Lane, 1996). 


• Pain relief is crucial because pain following upper abdominal surgery produces significant 

respiratory dysfunction (Vassilakopoulos et al., 2000). Effective analgesia and aggressive 

pulmonary toilet produce a speedier return of respiratory function and reduce postoperative 

respiratory complications. 

• Aggressive management of the entire perioperative experience following laparoscopic abdominal 

surgery using epidural local anethetics, NSAIDs, complete avoidance of opiates, early feeding, 

and ambulation has been associated with improved pain control, reduced complications, and 

decreased length of stay (Kehlet et al., 1999; Bardram et al., 1995; Bardram et al., 2000). 

• Use of laparoscopic procedures leads to less postoperative pain and shorter lengths of stay 

(McMahon, 1994). Many laparoscopic procedures are done on an outpatient basis, so pain control 

needs to be obtained expeditiously, prior to discharge. 

• Previous treatment of simple laparoscopic procedures was limited to oral and IV analgesics. With 

the advent of complicated laparoscopic procedures, advanced strategies for pain management such 

as intraspinal analgesics (as a part of an aggressive pain management approach) have been 

associated with more rapid discharge and improved outcomes. 



1 Multimodal analgesia using local anesthetic, 

NSAIDs and opiates provides improved pain 

control, decreased nausea, and faster 

discharge following laparoscopic 

cholecystectomy. 

Michaloliakou et al., 1996 I A 

2 Pain following upper abdominal surgery 

produces inspiratory muscle dysfunction. 

This dysfunction is reduced with analgesia. 

Vassilakopoulos et al., 2000 I A 


Version 1.2 




3 IV PCA morphine produces better analgesia 

than IM morphine, without any increase in 

postoperative hypoxemia. 

Wheatley et al., 1992 I A 

4 Patients using IV PCA morphine used more 

morphine and had better analgesia than 

patients receiving IM morphine on demand. 

IV PCA patients also experienced more 

fatigue and had less vigor than patients 

receiving IM morphine. 

Passchier et al., 1993 I A 

5 Epidural analgesia, with a combination of 

opiates and local anesthetic, provides better 

pain control during rest and activity, and is 

the treatment of choice. It is also associated 

with more rapid recovery of bowel function. 

Mulroy et al., 1996 

George et al., 1994 

Mann et al., 2000 

Liu et al., 1995 

III 

I 

I 

I 

A 

A 

A 

A 

6 Epidural analgesia is associated with less 

postoperative myocardial ischemia (than IV 

PCA with morphine). 

deLeon-Casasola et al., 1995 II-2 A 

7 For optimal analgesia, the thoracic epidural 

route should be used for pain relief after 

upper abdominal surgery. 

Wiebalck et al., 1997 

Chisakuta et al., 1995 

George et al., 1994 

I 

I 

I 

A 

A 

A 

8 Pain control with intercostal nerve block in 

combination with opiates is more effective 

than opiates alone after subcostal incisions. 

Intercostal nerve blocks do not significantly 

improve analgesia following midline 

incisions. 

9 Phenol with local anesthetic has been shown 

to increase the duration of intercostal block 

and improve analgesia following 


10 Infiltration of the incision/wound with local 

anethesia improved postoperative analgesia 

provided by epidural bupivicaine/morphine 

during mobilization and reduced the need for 

supplemental intramuscular morphine. 

11 Ketorolac given before or after laparoscopic 

cholecystectomy reduced postoperative pain 

and facilitated the transition to oral pain 

medication. 

12 Pain relief promotes return of respiratory 

function. 

Engberg et al., 1985 I B 

Maidatsi et al., 1998 I B 

Bartholdy et al., 1994 I B 

Lane, 1996 I A 

Vassilakopoulos et al., 2000 I A 


Version 1.2 




13 Aggressive perioperative management with 

epdural, NSAIDs, early feeding, and 

ambulation is associated with improved 

recovery and rapid discharge after 

laparoscopic colonic surgery. 

Kehlet et al., 1999 

Bardram et al., 1995 


II-3 

II-3 

II-3 

B 

B 

A 

14 Laparoscopic cholecystectomy is associated 

with less pain than open cholecystectomy. 

15 Patient-controlled epidural analgesia with a 

background infusion is more effective than 

patient-controlled epidural analgesia alone 

after gastrectomy. 

McMahon et al., 1994 I A 

Komatsu et al., 1998 I A 



Version 1.2 




Laparotomy 


Produces pain that is nociceptive (somatic and visceral) and neuropathic in nature. 


Pain from laparotomy is moderate to severe and lasts from days to weeks. 


• Analgesia at rest can be readily obtained with IV, IM, or IV PCA opiates. 

• Thoracic epidural analgesia with a combination of opiates and local anesthetic produces improved 

pain control during activities such as coughing, deep breathing, and ambulation. It is also 

associated with better satisfaction, more rapid recovery of bowel function and more rapid return to 

normal mental status in the elderly (Liu et al., 1995; Mann et al., 2000). 

• Adjuvant techniques, such as TENS and acupuncture, have not demonstrated great usefulness. 

• Regional analgesic techniques such as intercostal or paravertebral nerve block may be useful in the 

first 24 hours postoperatively. 

• Aggressive management of the entire perioperative experience following laparoscopic abdominal 

surgery using epidural, local anethetics, NSAIDs, complete avoidance of opiates, early feeding 

and ambulation has been associated with improved pain control, reduced complications, and 

decreased length of stay (Kehlet, 1995; Bardram et al., 1995; Bardram et al., 2000). 


Laparotomy may be associated with reductions in forced expiratory volume (FEV) ranging from 25 to 75 

percent and produce significant pulmonary complications. 



1 Epidural analgesia produces better pain control 

at rest and with activity. It is also associated 

with earlier return to normal mental status in 

the elderly, better satisfaction, and more rapid 

recovery of bowel function. 

Liu et al., 1995 

Mann et al., 2000 

I 

I 

A 

A 

2 Aggressive perioperative management with 

epidural, NSAIDs, early feeding, and 

ambulation is associated with improved 

recovery and rapid discharge after laparoscopic 

colonic surgery. 

Kehlet, 1999 



II-3 

II-3 

II-3 

B 

B 

A 



Version 1.2 




Laparoscopic Cholecystectomy 


Laparoscopic cholecystectomy produces pain that is nociceptive (somatic and visceral) and neuropathic in 

nature. 


Pain from laparoscopic cholecystectomy is mild to moderate lasting days (McMahon, 1994). 


Analgesia can be readily obtained with IV, IM, or oral opiates. Multimodal analgesia using local 

anesthetic, NSAIDs, and opiates provides improved pain control, decreased nausea, and faster discharge 

following laparoscopic cholecystectomy (Michaloliakou, 1996). Suprahepatic suction drains placed by the 

surgeon have been shown to reduce shoulder tip pain from retained carbon dioxide (CO 2 ) following 

laparoscopic cholecystectomy (Jorgensen, 1995). 


Laparoscopic cholecystectomy involves peritoneal insufflation of CO 2 gas. Invariably, residual CO 2 causes 

postoperative abdominal pain that may refer to the shoulder secondary to continued diaphragmatic 

irritation. It has been shown that active aspiration of insufflating gas at the conclusion of the operation 

results in less discomfort postoperatively (Fredman et al., 1994). 



1 Multimodal analgesia using local anesthetic, 

NSAIDs, and opiates provides improved pain 

control, decreased nausea, and faster discharge 

following laparoscopic cholecystectomy. 

Michaloliakou, 1996 I A 

2 Active removal of residual pneumoperitoneum 

reduces postoperative pain following laparoscopic 


3 Suprahepatic suction drains placed by the surgeon 

have been shown to reduce shoulder tip pain 

following laparoscopic cholecystectomy. 

Fredman et al., 1994 I A 

Jorgensen, 1995 II-3 B 



Version 1.2 




Nephrectomy 


Nephrectomy produces pain that is nociceptive (somatic and visceral) and neuropathic in nature. 


Pain from nephrectomy is mild to severe lasting days to weeks. 


• Nephrectomies are usually performed through one of three possible incisions: flank, subcostal, or 

thoracoabdominal (Whalley & Berrigan, 2000). Laparoscopic nephrectomy is also an accepted 

technique that may be less painful (Nicol et al., 1994). Each type of incision will invariably have 

different levels of pain/discomfort and discussion with surgeons preoperatively is warranted, so 

that an appropriate pain management plan is in place. 

• Thoracic epidural analgesia with a combination of opiates and local anesthetic produces improved 

pain control during activities such as coughing, deep breathing, and ambulation and is the superior 

technique. Oral/IV/IM opiates are also acceptable and efficacious, especially in the laparoscopic 

procedures. 

• Interpleural local anesthetics have been shown to be effective in reducing opiate requirements 

post-operatively (Greif et al., 1999). 

• Regional analgesic techniques such as intercostal or paravertebral nerve block may be useful in the 

first 24 hours postoperatively. 


Renal function and drug clearance must be considered in developing a postoperative analgesia plan. 

NSAIDs may not be appropriate for use in patients with decreased renal function. In addition, opiate 

compounds requiring renal elimination may accumulate and produce undesirable side effects in patients 

with poor renal clearance. 



1 Interpleural local anesthetics have been shown to 

be effective in reducing opiate requirements postoperatively. 

Greif et al., 1999 III B 



Version 1.2 



LOWER ABDOMINAL AND PELVIS SURGERY 


Operations of the lower abdomen and pelvis can produce both nociceptive (somatic and visceral) and 

neuropathic pain. 


Pain from lower abdomen and pelvic procedures generally ranges from moderate to severe in intensity 

lasting weeks to months. 


Effective pain control can be obtained using IM, IV, IV PCA, or intraspinal drug administration (see 

specific operations). Epidural opiates provide better postoperative analgesia with fewer side effects than 

intravenous PCA opiates. Intraspinal opiate administration may not be the optimal technique for patients 

scheduled for rapid discharge from the hospital. Intraspinal analgesic techniques provide better 

postoperative pain control in patients undergoing major lower abdominal or pelvic surgery. Once bowel 

function has been recovered, oral administration of combination opiate preparations or NSAIDs can be 

used to effectively control pain for the remainder of the admission and following discharge. 


• Epidural morphine provides better pain relief than patient-controlled intravenous morphine after 

hysterectomy (Eriksson-Mjoberg et al., 1997). 

• Decreased bowel motility may be further exacerbated by opiate administration. 

• Ambulation in the perioperative period is associated with a decreased risk of thromboembolic 

complications and more rapid recovery of bowel function (Bardram et al., 2000). 

• In the absence of significant motor block with intraspinal drug administration, patients should be 

encouraged to ambulate with assistance. 



1 Epidural opiates in the postoperative period 

provide better analgesia with fewer side 

effects than IV PCA morphine. 

Eriksson-Mjoberg et al., 1997 I A 

2 Ambulation in the perioperative period is 

associated with a decreased risk of 

thromboembolic complications and more 

rapid recovery of bowel function. 

Bardram et al., 2000 II-3 A 



Version 1.2 




Hysterectomy 


Hysterectomy produces both nociceptive (somatic and visceral) and neuropathic pain. 


Hysterectomy pain can range from mild to severe and may last days to weeks. In the event of a nerve 

injury, the pain may last weeks to years. 


• Wound infiltration with local anesthetic does not reduce opiate requirements following abdominal 

hysterectomy (Cobby & Reid, 1997). 

• IV PCA opiates result in better analgesia with fewer adverse effects than intermittent IM opiates 

and result in higher patient satisfaction (Egbert et al., 1990; Ballantyne et al., 1993). 

• Epidural morphine provides better pain relief with fewer side effects than intravenous PCA 

morphine following hysterectomy (Eriksson-Mjoberg et al., 1997). 

• NSAIDs do not produce preemptive analgesia following abdominal hysterectomy (Danou et al., 

2000; Rogers et al., 1995). However, they are associated with significant reductions in opiate 

administration when used as a part of the postoperative pain treatment regimen (Cobby et al., 

1999; Varrassi et al., 1999; Gabbott, 1997). 

• TENS units may be effective (Hamza et al., 1999; Chen et al., 1998). 



1 Wound infiltration with local anesthetic does not 

reduce morphine requirements after abdominal 

hysterectomy. 

Cobby & Reid, 1997 I A 

2 IV PCA opiates result in better analgesia with 

fewer adverse effects than intermittent IM opiates 

and result in higher patient satisfaction. 

Egbert et al., 1990 

Ballantyne, 1993 

I 

I 

A 

A 

3 Epidural morphine provides better pain relief 

with fewer side effects than IV PCA morphine. 

Eriksson-Mjoberg et al., 1997 I A 

4 TENS units may be effective. Hamza et al., 1999 

Chen et al., 1998 

5 NSAIDs do not produce preemptive analgesia. Danou, 2000 

Rogers et al., 1995 

I 

I 

I 

I 

B 

B 

D 

B 

6 NSAIDs reduce postoperative opiate 

requirements. 

Cobby et al., 1999 

Varrassi et al., 1999 

Gabbott, 1997 

I 

I 

I 

A 

A 

A 



Version 1.2 




Radical Retropubic Prostatectomy 


Radical retropubic prostatectomy produces postoperative pain that is primarily nociceptive in nature. 


Radical retropubic prostatectomy produces pain that is moderate to severe in intensity lasting weeks. 


• IV PCA opiates result in better analgesia with fewer adverse effects than intermittent IM opiates, 

and result in higher patient satisfaction (Egbert et al., 1990; Ballantyne et al., 1993). 

• Postoperative administration of ketorolac instead of IV PCA morphine is associated with earlier 

recovery of bowel function, shorter hospitalization, and lower overall costs (See et al., 1995). 

• Epidural analgesia provides superior pain control and may be associated with reduced 

postoperative pain for several weeks following surgery (Shir et al., 1994; Gottschalk et al., 1998). 

• Postoperative administration of ketorolac is an effective adjuvant for improving postoperative 

epidural analgesia (Grass et al., 1993). 

• Intraoperative administration of ketorolac does not decrease postoperative pain or improve 

analgesia (Fredman et al., 1996). 

• FasTENS is an effective adjuvant for postoperative analgesia following retropubic prostatectomy 

(Merrill, 1989). 


See general statement above. 



1 IV PCA opiates result in better analgesia with fewer 

adverse effects than intermittent IM opiates and result in 

higher patient satisfaction. 

Egbert et al., 1990 

Ballantyne et al., 1993 

I 

I 

A 

A 

2 Epidural analgesia may be used to provide superior pain 

control and may be associated with reduced postoperative 

pain for several weeks. 

Shir et al., 1994 

Gottschalk et al., 1998 

I 

A 

3 Postoperative administration of ketorolac instead of IV 

PCA morphine is associated with earlier recovery of bowel 

function, shorter hospitalization, and lower overall costs. 

4 Postoperative administration of ketorolac is a useful 

adjuvant to epidural analgesia to improve postoperative 

pain control. 

5 Intraoperative administration of Ketorolac does not 

decrease postoperative pain or improve analgesia. 

6 FasTENS is an effective adjuvant for postoperative 

analgesia following retropubic prostatectomy. 

See et al., 1995 II-3 B 

Grass et al., 1993 I A 

Fredman et al., 1996 I D 

Merrill, 1989 I A 



Version 1.2 




Inguinal Hernia 


Inguinal herniorrhaphy produces both nociceptive and neuropathic pain. Certain types of hernia repair are 

more painful (Wellwood et al., 1998). 


Pain produced is generally mild to severe lasting weeks. Neuropathic pain following inguinal 

herniorrhaphy may last weeks to years. 


Regional anesthesia (local field block, nerve block, spinal, or epidural) may have advantages in preventing 

postoperative pain and can be associated with fewer postoperative side effects such as nausea and vomiting, 

which can lead to delayed discharge (Song et al., 2000; Moiniche et al., 1998; Ding & White, 1995). 

Regardless of the choice of anesthesia for the case, regional analgesia, including local field block or 

peripheral nerve block, may be used to provide prolonged postoperative analgesia (Wassef et al., 1998; 

Ding & White, 1995). Preoperative administration of ketorolac reduces postoperative pain following 

inguinal herniorrhaphy and the need for additional postoperative analgesic medication. There is no 

advantage to delivering the medication within the wound or giving IV over IM drugs (Ben-David et al., 

1996). 


See general considerations. 



1 Regional anesthesia may have advantages in preventing 

postoperative pain and can be associated with fewer 

postoperative side effects. 

Song et al., 2000 

Moiniche et al., 1998 

Ding & White, 1995 

I 

I 

I 

A 

B 

A 

2 Regional analgesia, including local field block or 

peripheral nerve block, may be used to provide 

prolonged postoperative analgesia. 

3 Preoperative administration of ketorolac reduces 

postoperative pain following inguinal herniorrhaphy and 

the need for additional postoperative analgesic 

medication. There is no advantage to delivering the 

medication within the wound or giving IV over IM drug. 

Wassef et al., 1998 I A 

Ben-David et al., 1996 I B 



Version 1.2 



BACK/SPINAL SURGERY 


Back and spinal procedures produce nociceptive and neuropathic pain. 


Pain from back and spinal procedures is mild to severe in intensity and may last weeks to months. Back 

surgery is also associated with moderate to severe paraspinal muscle spasm. These patients may develop 

chronic pain syndromes lasting years (e.g., post-laminectomy pain syndrome). 


• PO/IM/IV opioid medications are commonly used. IV PCA is the treatment of choice for 

moderate to severe pain. Placement of epidural catheters for postoperative analgesia can be 

accomplished preoperatively from a percutaneous approach, as well as by direct placement by the 

surgeon during the course of the operation. 

• Operations on the spinal cord often involve laminectomy and bone grafting, and may include 

opening the dura around the spinal cord. These procedures may limit the role of intraspinal 

delivery of pain medications. The use of epidural or intrathecal opiates for control of pain after 

back surgery is not widespread. 


• Operations on the spine at any level are frequently done for patients who have experienced chronic 

pain. Such patients may have typical complications of chronic pain, including depression, anxiety, 

irritability, and, if opioid analgesics were required preoperatively, a relative tolerance to opioid 

medications. All of these factors may complicate pain assessment and treatment in the 

postoperative period. 

• As with any neurologic procedure, postoperative patients require careful monitoring of neurologic 

function, especially the assessment of sensory, motor, and autonomic functioning. 

• NSAIDs may affect healing of spinal fusions (Glassman et al., 1998). 



1 NSAIDs may affect healing of spinal fusions. Glassman et al., 1998 II-1 A 



Version 1.2 




Laminectomy 


A laminectomy causes nociceptive and neuropathic pain. 


Laminectomy causes pain of mild to severe intensity lasting weeks. 


• Laminectomy pain is treated with IV PCA, IV, IM (Colwell & Morris, 1995) and oral medication, 

as more of these procedures are done on an outpatient basis. Nonsteroidals may be effective 

(Rosenhow et al., 1998; Rowe et al., 1992). 

• Regional techniques (epidural) can be used for superior postoperative pain control, but are not 

common (Ibrahim et al., 1986; Joshi et al., 1995; Kundra et al., 1997). 

• Local infiltration of the incision may be helpful (Cherian et al., 1997). 

• TENS is not helpful (McCallum et al., 1988). 


This group of patients may be on significant doses of oral analgesics preoperatively and may need larger 

doses postoperatively than an opioid-naïve patient. 



1 Laminectomy pain is treated with IV Colwell & Morris, 1995 I A 

PCA, IV, IM, and oral medications. 

2 Nonsteroidals may be effective. Rosenhow et al., 1998 

Rowe et al., 1992 

I 

I 

A 

A 

3 Regional techniques can be used for 

superior postoperative pain control. 

Kundra et al., 1997 

Joshi et al., 1995 

Ibrahim et al., 1986 

I 

I 

I 

C 

B 

B 

4 Local infiltration of the incision may be Cherian et al., 1997 I B 

helpful. 

5 TENS is not helpful. McCallum et al., 1988 I B 



Version 1.2 




Spinal Fusion 


Spinal fusion causes pain that is nociceptive and neuropathic in nature. 


Spinal fusion pain lasts months and is moderate to severe in intensity. 


• Pain is addressed with IV PCA, IV, and IM medication with conversion to oral medication over a 

period of several days. 

• Regional anesthesia is not used; pain relief is not superior to patient-controlled analgesia (Cohen 

et al., 1997; France et al., 1997). 

• NSAIDs can provide analgesia, but there are concerns regarding increased rates of non-union 

following NSAID use (Glassman et al., 1998). 

• Patients may use external braces. 


Patients may be on preoperative analgesics and receive larger doses of postoperative medications. 



1 Regional anesthesia is not used; pain relief is France et al., 1997 

I C 

not superior to patient-controlled analgesia. Cohen et al., 1997 

I A 

2 NSAIDs are helpful. Reuben et al., 1998 I C 

3 There are concerns regarding increased rates 

of non-union following NSAID use. 


Glassman et al., 1998 II-1 A 


Version 1.2 



SURGERY OF EXTREMITIES/VASCULAR SURGERY 


Extremities and vascular procedures may result in pain that is both nociceptive and neuropathic. 


Postoperative pain following extremity surgery may range from mild to severe in intensity and last days to 

weeks. If long-term anatomic abnormality or neuropathic injury results from the surgical procedure, pain 

may last from weeks to years. 


There are a wide variety of techniques that may be used to provide anesthesia and postoperative analgesia 

for surgical procedures involving the extremities. These include the following: 



• Interscalene brachial plexus blocks 

• Supraclavicular brachial plexus blocks 

• Infraclavicular brachial plexus blocks 

• Axillary brachial plexus blocks 

• Upper extremity peripheral nerve blocks 

• Lumbar plexus blocks 

• Femoral nerve blocks 

• Fascia iliaca blocks 

• Lateral femoral cutaneous nerve blocks 

• Obturator nerve blocks 

• Saphenous nerve blocks 

• Ankle blocks 

• Sciatic nerve blocks 

• Popliteal nerve blocks 

• Intra-articular injections 

• Wound or joint infusions of local anesthetic 


• TENS 

• NSAIDs 



• Ice 

Extremity surgery lends itself to the use of regional anesthesia/analgesia techniques. Epidural analgesia is 

particularly attractive in terms of establishing early mobility, minimizing thromboembolic complications, 

and improving graft survival in the setting of peripheral vascular surgery. Regional anesthesia/analgesia 

techniques are associated with fewer complications, reduced morbidity and mortality, a high patient 

satisfaction rate, and the ability to discharge the patient with prolonged analgesia (Rodgers et al., 2000). 

Postoperative pain control can be obtained using oral, IM, and IV analgesia. Postoperative pain control 

may also be supplemented by physical and psychological interventions. The ideal pain control method 

should have minimal side effects, maintain mental clarity, and allow early ambulation and movement in the 



Lower extremity surgery is associated with a high degree of morbidity related to venous thromboembolic 

complications. Because of this, intermittent leg and foot compression devices are commonly used in 

conjunction with various anticoagulant regimens. The potential for complications associated with the 


Version 1.2 



combination of anticoagulants and regional anesthesia/analgesia must be taken into consideration in 

developing a perioperative pain control plan. 

Operations requiring a cast or other form of external fixation for stabilization require frequent postoperative 

evaluation of circulation and neurologic functions. If a regional anesthetic/analgesic is to be used 

for postoperative pain control, this must be planned in conjunction with the surgeon so that it does not 

compromise required postoperative evaluation and monitoring. The presence of a regional anesthetic may 

prevent the patient from reporting a painful area of pressure or moving spontaneously in response to 

prolonged pressure on an area of the body, resulting in injury if appropriate monitoring and padding are not 

utilized. 

Indwelling catheters may be inserted with many types of regional anesthetic/analgesic techniques. This 

facilitates delivery of continuous or intermittent local anesthetic +/- opioid or clonidine or 

agonist/antagonist through the catheter to provide postoperative pain relief. This can be done both as an 

inpatient and as an outpatient. 

In many settings, the use of regional anesthesia/analgesia provides superior postoperative analgesia 

compared to oral, intramuscular, or intravenous opioid analgesics. 

Minor Surgery: 

Minor operations, such as carpal tunnel release, ganglion cystectomies, and other minor peripheral 

procedures are frequently performed on an outpatient basis, using local or regional anesthesia. Pain 

resulting from these procedures can be readily controlled using mild opiate analgesics supplemented by 

NSAIDs. Local or regional anesthesia used intraoperatively will provide analgesia in the postoperative 

period. In some cases, addition of other drugs (e.g., clonidine) to the local anesthetic will prolong the 

duration of action (Reinhart et al., 1996). 



1 Regional anesthesia/analgesia techniques are 

associated with fewer complications, reduced 

morbidity and mortality, a high patient 

satisfaction rate, and the ability to discharge the 

patient with prolonged analgesia. 

Rodgers et al., 2000 I A 

2 In some cases, addition of other drugs (e.g., 

clonidine) to the local anesthetic will prolong the 

duration of action. 

Reinhart et al., 1996 I A 



Version 1.2 



SURGERY OF EXTREMITIES 

Total Hip Replacement 


Pain from total hip replacement is primarily nociceptive in nature. 


Total hip replacement produces mild to severe pain of several days' to weeks' duration. 


Postoperative analgesia following total hip replacement may be provided by a number of methods. These 

include the following: 





• NSAIDs 


• Mixed agonist-antagonist opioids 


Intravenous morphine administered at the end of surgery to spontaneously breathing patients is associated 

with rapid postoperative pain control, decreased opiate doses, and reduced respiratory depression (Pico et 

al., 2000). Lumbar plexus blocks performed prior to hip surgery are associated with a moderate reduction 

in blood loss and a significant improvement in early analgesia (Stevens et al, 2000). Three-in-one block 

does not contribute in a significant fashion to postoperative pain control following total hip arthroplasty 

using the posterior approach (Uhrbrand et al., 1992). 

There is a significant potential for developing thromboembolic complications following total hip 

replacement. Medical interventions intended to reduce this risk may dictate the choice of anesthetic and 

postoperative analgesic technique by increasing the risk associated with the performance of neuraxial 

anesthetic/analgesic techniques. Careful planning with the surgeon and adherence to guidelines for 

neuraxial anesthesia/analgesia in the presence of anticoagulants (ASRA, 1998) will help to minimize the 

risk. 

At rest, epidural analgesia is slightly better than IV patient-controlled analgesia (Wulf et al., 1999). 

Intrathecal administration of morphine in small doses is capable of providing excellent analgesia 

(Slappendel et al., 1999). The choice of fentanyl or morphine along with bupivicaine does not appear to 

make a significant difference in postoperative pain relief or side effects (Berti et al., 1998). Continuous 

spinal anesthesia may provide more complete analgesia and less muscle spasm than epidural analgesia 

(Mollmann et al., 1999). Intrathecal clonidine is capable of prolonging the duration of spinal anesthesia, 

but is markedly inferior to intrathecal morphine in providing subsequent postoperative analgesia (Fogarty et 

al., 1993). Administration of ketorolac tromethamine to patients receiving intrathecal opiates for 

postoperative pain control will reduce the need for additional opiates, but will not change the incidence of 

side effects (Fogarty et al., 1995). 

Patients may typically be converted to oral analgesics on the second to third postoperative day. Regularly 

administered oral opiates are capable of providing good postoperative pain control at that time (Bourke et 

al., 2000). 


Version 1.2 





1 Intravenous morphine administered at the end of 

surgery to spontaneously breathing patients is 

associated with more rapid postoperative pain control, 

decreased opiate doses, and reduced respiratory 

depression. 

Pico et al., 2000 I A 

2 Lumbar plexus blocks performed prior to hip surgery 

are associated with a moderate reduction in blood loss 

and a significant improvement in early analgesia. 

3 Three-in-one block does not contribute in a significant 

fashion to postoperative pain control following total 

hip arthroplasty using the posterior approach. 

4 Adherence to guidelines for neuraxial 

anesthesia/analgesia in the presence of anticoagulants 

will help to minimize the risk of thromboembolic 

complications. 

5 At rest, epidural analgesia is slightly better than IV 

patient-controlled analgesia. 

Stevens et al., 2000 I A 

Uhrbrand et al., 1992 I A 

ASRA, 1998 

Wulf et al., 1999 I B 

6 Intrathecal administration of morphine in small doses is 

capable of providing excellent analgesia. 

Slappendel et al., 

1999 

I 

A 

7 The choice of fentanyl or morphine along with 

bupivicaine does not appear to make a significant 

difference in postoperative pain relief or side effects. 

Berti et al., 1998 I B 

8 Continuous spinal anesthesia may provide more 

complete analgesia and less muscle spasm than 

epidural analgesia. 

Mollmann et al., 

1999 

I 

B 

9 Intrathecal clonidine is capable of prolonging the 

duration of spinal anesthesia, but is markedly inferior 

to intrathecal morphine in providing subsequent 

postoperative analgesia. 

Fogarty et al., 1993 

10 Administration of ketorolac tromethamine to patients 

receiving intrathecal opiates for postoperative pain 

control will reduce the need for additional opiates, but 

will not change the incidence of side effects. 

11 Patients may typically be converted to oral analgesics 

on the second to third postoperative day. Regularly 

administered oral opiates are capable of providing good 


Fogarty et al., 1995 I A 

Bourke et al., 2000 I A 



Version 1.2 




Total Knee Replacement 


The pain from total knee replacement is typically nociceptive in nature. 


Total knee replacement produces moderate to severe pain of several days' to weeks' duration. 


Postoperative pain control following total knee replacement surgery can be provided with a variety of 

techniques. These include the following: 








• NSAIDs 




Pain is frequently exacerbated by the ongoing physical therapy that is vital to the long-term outcome of the 

surgery. The use of epidural analgesia or continuous femoral nerve block following total knee arthroplasty 

provides superior pain control as compared to opioids alone and is associated with a shorter recovery time. 

Improved pain control facilitates participation in physical therapy and improves outcome (Capdevila et al., 

1999; Singelyn et al., 1998). For this reason, pain must be aggressively treated following total knee 

arthroplasty. 

The potential for developing thromboembolic complications following total knee replacement is 

significant. Medical interventions intended to reduce this risk play a role in the choice of intraoperative 

anesthetic and postoperative analgesic technique. Careful planning with the surgeon and adherence to the 

guidelines (ASRA, 1998) for neuraxial anesthesia/analgesia in the presence of these drugs will help to 

minimize the risks. 

Single shot, continuous epidural, and continuous regional techniques produce better overall pain control 

than nonregional techniques (Allen et al., 1998; Ganapathy et al., 2000; Singelyn & Gouverneur, 2000). 

The addition of a sciatic nerve block to a femoral nerve block does not significantly improve postoperative 

pain control when compared to the femoral nerve block alone (Allen et al., 1998). Intrathecal opioids may 

be used to improve postoperative pain control (Cole et al., 2000). Although they have been effective in 

other arthroscopy settings, intra-articular opioids are not effective for postoperative pain control following 

total knee arthroplasty (Klasen et al., 1999; Mauerhan et al., 1997). Intravenous regional delivery of 

opiates does not improve postoperative pain control over IM opiates following total knee arthroplasty 

(McSwiney et al., 1997). 


Version 1.2 





1 Improved pain control facilitates participation Capdevila et al.,1999 

I A 

in physical therapy and improves outcome. Singelyn et al., 1998 

I A 

2 Adherence to the guidelines for neuraxial 

anesthesia/analgesia will help to minimize the 

risk of thromboembolic complications. 

ASRA, 1998 

3 Single shot, continuous epidural, and 

continuous regional techniques produce better 

overall pain control. 

Singelyn & Gouverneur, 2000 

Ganapathy et al., 2000 

Allen et al., 1998 

I 

I 

I 

A 

B 

B 

4 The addition of a sciatic nerve block to a 

femoral nerve block does not significantly 

improve postoperative pain control when 

compared to the femoral nerve block alone. 

5 Intrathecal opioids may be used to improve 


6 Intra-articular opioids are not effective for 

postoperative pain control following total knee 

arthroplasty. 

7 Intravenous regional delivery of opiates does 

not improve postoperative pain control over IM 

opiates following total knee arthroplasty. 

Allen et al., 1998 I E 

Cole et al., 2000 I B 

Klasen et al., 1999 I E 

McSwiney et al., 1997 I E 



Version 1.2 




Knee Arthroscopy and Arthroscopic Joint Repair 


Knee arthroscopy and arthroscopic joint repair procedures typically result in pain that is nociceptive in 

nature. 


Knee arthroscopy and arthroscopic joint repair procedures produce pain that is mild to severe lasting days 

to weeks. 


Postoperative analgesia following knee arthroscopy and arthroscopic joint repair may be provided using a 

number of techniques. These include the following: 








• Wound or joint infusions of local anesthetic 


• NSAIDs 



• Ice 


As a rule, the majority of these procedures are performed on an outpatient basis. The ability to control pain 

and safely discharge the patient home plays a significant role in the choice of anesthetic and postoperative 

analgesic technique. The use of a combined sciatic and femoral nerve block provides good surgical 

conditions and prolonged analgesia resulting in reduced cost and hospital stays compared to general 

anesthesia (Sansone et al., 1999). A local anesthetic infusion either into the joint or along a nerve bundle 

may be safely used to provide excellent postoperative analgesia. There is also good evidence that 

prolonged analgesia following arthroscopic knee surgery may be obtained with the use of intra-articular 

morphine or clonidine that is better than local anesthetic alone (Stein et al., 1991; Dalsgaard et al., 1994; 

Gentili et al., 1996; Kanbak et al., 1997; Cepeda et al., 1997). Keeping a tourniquet inflated for 10 minutes 

after administering intra-articular morphine provides superior analgesia and decreases the need for 

supplemental analgesics compared to patients in whom the tourniquet is released immediately after 

injecting morphine into the joint (Whitford et al., 1997). Some questions remain about the efficacy of 

intra-articular morphine following knee surgery although the preponderance of the literature supports its 

use (Christensen et al., 1996). The use of ice or a “Cryo/Cuff” device following knee arthroscopy will help 

to control both pain and swelling (Whitelaw et al., 1995). 


Version 1.2 





1 The use of a combined sciatic and femoral 

nerve block provides good surgical 

conditions and prolonged analgesia. 

Sansone et al., 1999 II-3 B 

2 Prolonged analgesia that is better than local 

anesthetic alone may be obtained with the 

use of intra-articular morphine or clonidine. 

Stein et al., 1991 

Dalsgaard et al., 1994 

Gentili et al., 1996 

Kanbak et al., 1997 

Cepeda, 1997 

I 

I 

I 

I 

I 

A 

A 

A 

A 

A 

3 Keeping a tourniquet inflated for 10 minutes 

after administering intra-articular morphine 

provides superior analgesia and decreases the 

need for supplemental analgesics. 

Whitford et al., 1997 I A 

4 The preponderance of the literature supports 

the use of intra-articular morphine following 

knee surgery. 

Christensen et al., 1996 

(Article is an example of reference for 

this statement.) 

I 

A 

5 Ice or a “Cryo/Cuff" device will help to 

control both pain and swelling following 

arthroscopy. 

Whitelaw et al., 1995 I B 



Version 1.2 




Amputation 


Postoperative pain following amputation of an extremity is both nociceptive and neuropathic in nature. 


Pain following amputation is generally moderate to severe in intensity and may last from days to years. 


Postoperative pain control following amputation may be provided with a variety of techniques. These 

include the following: 





• Infraclavicular brachial plexus blocks 

• Axillary brachial plexus blocks 

• Upper extremity peripheral nerve blocks 



• Fascia iliac blocks 

• Ankle blocks 



• Direct peripheral nerve local anesthetic infusions 


• NSAIDs 




If patients have preoperative pain, aggressive preoperative intervention to reduce pain perception has been 

theorized to reduce the incidence of phantom limb pain postoperatively. Preoperative infusions of local 

anesthetic alone or local anesthetic with opiate and/or clonidine may be useful in minimizing postoperative 

phantom limb pain (Bach et al., 1988; Jahangiri et al., 1994). This intervention remains controversial, as 

available studies do not produce consistent results. Some studies using preoperative infusions have not 

demonstrated any benefit (Nikolajsen et al., 1997; Elizaga et al., 1994). This may reflect the lack of 

uniform techniques or the variety of conditions leading to a need for amputation. Patients receiving 

preoperative, intraoperative, and postoperative epidural bupivicaine and morphine did not have any 

reduction in hyperalgesia, allodynia, or wind-up-like pain at one week or six months when compared to 

patients receiving epidural bupivicaine and morphine postoperatively alone (Nikolajsen et al., 1997). 

Postoperative infusions of local anesthetic along the sciatic or posterior tibial nerve are a safe and effective 

method for the relief of postoperative pain but do not prevent residual or phantom limb pain in patients 

undergoing amputation because of ischemic changes secondary to peripheral vascular disease (Pinzur et al., 

1996). Postoperative infusion of local anesthetic into nerve sheaths provides excellent postoperative 

analgesia following upper extremity amputation, but does not affect long term phantom limb pain 

(Enneking et al., 1997; Iacono et al., 1987). 

In patients with a significant component of phantom limb pain, tricyclic antidepressants or antiseizure 

medications may need to be initiated in the postoperative period (Baron et al., 1998). 


Version 1.2 



If an epidural was utilized preoperatively or intraoperatively, it may be continued for postoperative pain 

control. TENS treatment of below-knee amputation (BKA) is not supported (Finsen et al., 1988). 

Patients are typically capable of conversion to oral analgesics within two to three days following their 

operation. 



1 Preoperative infusions of local anesthetic 

alone or local anesthetic with opiate and/or 

clonidine may be useful in minimizing postoperative 

phantom limb pain. 

Jahangiri et al., 1994 

Bach et al., 1988 

I 

I 

B 

B 

2 Some studies using preoperative infusions 

have not demonstrated any benefit. 

Nikolajsen et al., 1997 

Elizaga et al., 1994 

I 

I 

D 

D 

3 Patients receiving preoperative, 

intraoperative, and postoperative epidural 

bupivicaine and morphine had outcomes 

similar to patients receiving epidural 

bupivicaine and morphine postoperatively 

alone. 

Nikolajsen et al., 1997 I D 

4 Postoperative infusions of local anesthetic 

along the sciatic or posterior tibial nerve are 

a safe and effective method for the relief of 

postoperative pain but do not prevent 

residual or phantom limb pain. 

Pinzur et al., 1996 

Pinzer letter 

I 

III 

A 

C 

5 Postoperative infusions of local anesthetic 

into nerve sheaths provide excellent 

postoperative analgesia following upper 

extremity amputation, but do not affect long 

term phantom limb pain. 

6 In those patients with a significant 

component of phantom limb pain, tricyclic 

antidepressants or anti-epileptic medications 

may need to be initiated in the postoperative 

period. 

Enneking et al., 1997 

Iacono et al., 1987 

Baron et al., 1998 

II-3C 

Review 

paper; not 

rated 

7 TENS treatment of BKA is not supported. Finsen et al., 1988 I D 



Version 1.2 




Shoulder – Open Rotator Cuff Repair or Arthroscopic Sub-acromial Decompression 


Extensive shoulder surgery causes pain that is nociceptive in nature. 


Extensive shoulder surgery causes pain that is moderate to severe and lasts for weeks. 


Pain control following shoulder surgery may be achieved using a variety of techniques. These include the 

following: 





• Wound or joint infusions of local anesthetics 


• NSAIDs 


• Agonist-antagonist analgesics 

• Ice 


Most of shoulder surgery operations are currently performed on an outpatient basis. Reasons for 

unanticipated hospital admission include poorly controlled pain, nausea, vomiting, or sedation. Using 

techniques that minimize the need for centrally acting drugs will help to minimize undesirable side-effects 

and the need for unplanned hospital admission (D'Alessio et al., 1995). Using NSAIDs as a part of the 

postoperative pain management plan following subacromial decompression significantly reduces the need 

for additional analgesics (Hoe-Hansen & Norlin, 1999). 

Many centers routinely do these operations with regional anesthetics, with postoperative analgesic effects 

lasting up to 24 hours. Regional anesthesia can be utilized as a sole anesthetic or in combination with a 

general anesthetic to provide postoperative pain control (Al-Kaisy et al., 1998). Regional analgesic 

techniques may be either single shot, continuous infusion, or patient-controlled. Regional anesthetic blocks 

may be performed either preoperatively or postoperatively and provide improved pain control as compared 

to opioid analgesics alone (Borgeat, 2000; Borgeat et al., 1998; Lehtipalo et al., 1999). Suprascapular 

nerve blocks may provide a significant degree of postoperative analgesia (Ritchie et al., 1997). The 

addition of opioid analgesics to local anesthetics for interscalene block does not improve the quality or 

duration of analgesia as compared to local anesthetics alone (Flory et al., 1995). The addition of clonidine 

or the mixed agonist-antagonist opioid compounds to local anesthetic has been shown to prolong analgesia 

for brachial plexus blocks. 

Patients may be sent home with pain pumps that deliver local anesthetic into the wound or along nerve 

bundles, in addition to oral medications and instructions to use ice to minimize pain and swelling (Savoie et 

al., 2000). 


Version 1.2 





1 Techniques that minimize the need for centrally 

acting drugs will help to minimize undesirable 

side-effects and unplanned hospital admission. 

D'Alessio et al., 1995 III B 

2 NSAIDs following subacromial decompression 

significantly reduce the need for additional 

analgesics. 

3 Regional anesthesia can be utilized as a sole 

anesthetic or in combination with a general 

anesthetic to provide postoperative pain control. 

Hoe-Hansen & Norlin, 1999 I A 

Al-Kaisy et al., 1998 I A 

4 Regional anesthetic blocks may be performed 

either preoperatively or postoperatively and 

provide improved pain control as compared to 

opioid analgesics alone. 

Borgeat, 2000 

Lehtipalo et al., 1999 

Borgeat et al., 1998 

I 

I 

I 

A 

B 

A 

5 Suprascapular nerve blocks may provide a 

significant degree of postoperative analgesia. 

6 The addition of opioid analgesics to local 

anesthetics for interscalene block does not improve 

the quality or duration of analgesia as compared to 

local anesthetic alone. 

7 Patients may be sent home with pain pumps that 

deliver local anesthetic into the wound or along 

nerve bundles in addition to oral medications and 

instructions to use ice to minimize pain and 

swelling. 

Ritchie et al., 1997 I A 

Flory et al., 1995 I E 

Savoie et al., 2000 I A 



Version 1.2 



SURGERY OF EXTREMITIES/VASCULAR SURGERY 

Vascular Surgery 

The vast majority of vascular surgical procedures involve the neck, abdomen, or lower extremities. 

Vascular bypass procedures to the upper extremities are relatively uncommon. 


Vascular bypass procedures of the extremities produce pain that is nociceptive in nature. 


Vascular surgery pain is mild to moderate in intensity and lasts days to weeks. Patients may continue to 

have ischemic pain in nonperfused areas. 


Postoperative pain control for vascular surgery can be obtained by using a variety of techniques. Postoperative 

pain control for the neck and abdomen are covered in other areas of this document. 

There are a wide variety of techniques for pain control for the lower extremities following vascular surgery. 

These include the following: 






• Saphenous nerve blocks 




• TENS 

• NSAIDs 




These patients are frequently anticoagulated in the perioperative period. Therefore, close cooperation with 

the surgeon is required to utilize a regional anesthetic/analgesic. This is especially pertinent when 

removing a catheter used to provide intrathecal or epidural analgesia for postoperative pain control. 

Guidelines have been published (ASRA, 1998) to help minimize the risks associated with neuraxial 

anesthetic and analgesic techniques in the presence of perioperative anticoagulation. 

Supplementing conventional opioids with an epidural infusion of local anesthetic may benefit vascular 

surgery patients by decreasing the incidence of thromboembolism and graft occlusion after vascular bypass 

surgery. In addition, the use of regional anesthesia intraoperatively and postoperatively has been associated 

with decreased morbidity and mortality following vascular surgical procedures (Tuman et al., 1991; 

Christopherson et al., 1993; Rodgers et al., 2000). Peripheral nerve blocks may be used to provide superior 

analgesia following femoropopliteal bypass as compared to IV PCA alone (Griffith et al., 1996). 


Version 1.2 





1 The use of regional anesthesia intraoperatively 

and postoperatively has been associated with 

decreased morbidity and mortality following 

vascular surgical procedures. 

Tuman et al., 1991 

Christopherson et al., 1993 

Rodgers et al., 2000 

I 

I 

I 

A 

C 

A 

2 Peripheral nerve blocks may be used to provide 

superior analgesia following femoropopliteal 

bypass as compared to IV PCA alone. 

Griffith et al., 1996 I A 





OPTIONS FOR POSTOPERATIVE PAIN MANAGEMENT: 

NON-PHARMALOGIC MANAGEMENT 

Version 1.2

Version 1.2 




COGNITIVE MODALITIES 

INTRODUCTION 

Cognitive modalities, such as distraction, relaxation and hypnosis, have 

been successfully utilized as adjuncts to other analgesic interventions in 

the perioperative period. 

These non-pharmacologic interventions have the ability to improve 

analgesia without producing side effects or limiting the application of other 

techniques. This gives them the potential for application in a wide variety 

of settings. In addition, addressing other issues, such as anxiety that may 

or may not be adequately treated with traditional pharmacologic methods 

of pain control, may improve overall patient satisfaction. 

Although the data available to define the appropriate settings for the use of 

cognitive modalities is limited, the potential benefit and minimal downside 

risks for these techniques means that they should be considered without 

hesitation. 

Non-pharmacologic Management Page 1

Version 1.2 



DISTRACTION, RELAXATION 

Distraction and relaxation training are useful as an adjunct to analgesic interventions. Many relaxation 

techniques are available (McCaffery & Beebe, 1989; Williams, 1996). Biofeedback—assisted relaxation— 

uses an external device to help the patient learn to relax specific muscle groups. Distraction can include 

music and imagery (Good et al., 1999; Bruehl et al., 1993). Relaxation/distraction techniques have been 

widely evaluated (Good, 1996; Seers & Carroll, 1998) and do not have to be complex to be effective. 

Since evidence does not favor one strategy over others in postoperative pain management, patients should 

be provided information about different relaxation or distraction techniques and assisted in choosing the 

strategy that they are most motivated to learn and practice. 

Advantages: 

• No prior patient training is required, but for optimal results, distraction and relaxation techniques 

training should be initiated preoperatively to allow the patient to practice. 

• Relaxation techniques may benefit the patient by reducing muscular arousal and distracting from 

painful sensations. They also reduce anxiety and increase the patient’s sense of control. 

• Distraction skills and relaxation techniques can be practiced at home and used in any clinical 

setting. 

• Strategies, such as breathing techniques, can be taught in only 10 to 15 minutes, but do require 

periodic social reinforcement through encouragement and coaching. 

• These strategies are appropriate for most patients but may be of special use in situations with a 

patient who expresses interest in learning them; has anxiety; expresses a wish to reduce or limit 

analgesic medications; or who should learn skills in anticipation of prolonged pain. 

Disadvantages: 

• Biofeedback training requires special equipment and more extensive clinician training. 

• Better benefit is achieved when patients are taught strategies prior to the operative procedure 

(Morgan et al., 1985). 

Complications: 

• If planned in conjunction with patient preferences, there should be no complications associated 

with the cognitive modalities (Turk & Okifuji, 2000). 

Contraindications: 

• Cognitive modalities require that patients understand the information and instructions involved in 

the use of various treatments. These modalities will be inappropriate for use with patients who are 

significantly cognitively impaired and unable to comprehend the information included with the 

cognitive modalities (e.g., comatose patients, certain stroke patients, patients who have difficulty 

with the language of the person available to offer the treatments). 

• Cognitive therapies require cooperation and practice. These interventions would be 

contraindicated for use with patients who are uncooperative, unable, or unwilling to practice the 

necessary behaviors required for successful use of cognitive modalities (Melzack et al., 1980; 

Turk et al., 2000). 


Version 1.2 




Intervention 

Source of Evidence QE R 

1 Distraction and relaxation techniques are useful as 

adjuncts to analgesic interventions. 

Good, 1996 

Seers & Carroll, 1998 

Bruehl et al., 1993 

Good et al., 1999 

III 

III 

I 

I 

A 

A 

A 

A 

2 Distraction techniques have shown benefit in relief 

of postoperative pain in : 

• Abdominal operation 

• Hysterectomy 

• Coronary artery bypass graft 

• Chest tube removal 

Good et al., 1999 

Broscious, 1999 

Madden et al., 1978 

Miro & Raich, 1999 

Zimmerman et al., 1996 

I 

I 

I 

I 

I 

A 

A 

A 

A 

A 

3 Better benefit is achieved when patients are taught 

strategies prior to the operative procedure. 

Morgan et al., 1985 III A 



Version 1.2 



HYPNOSIS 

Hypnosis is a state of focused attention with a reduction of external awareness and a suspension of critical 

judgment. Contrary to popular belief, hypnosis does not imply suggestibility but rather the ability to focus 

attention to the exclusion of other stimuli. There are several mechanisms on which hypnosis is thought to 

have its beneficial effect. 

Advantages: 

• May decrease perioperative pain 

• May reduce analgesic and sedative requirements 

• May decrease postoperative anxiety 

• Improved patient satisfaction 

• Takes seconds to minutes to achieve entrance to a hypnotic state 


• Requires a professional trained in hypnosis 

• May not work for all patients 

• Social stigma associated with its use 

DISCUSSION 

Most data on hypnosis for perioperative pain are from case reports. The few randomized controlled trials 

have conflicting results on efficacy, though risks associated with its use appear to be minimal. In at least 

one well-designed randomized, placebo-controlled trial, hypnosis was associated with improvements in 

pain and anxiety, reduction in analgesic requirements, and greater patient satisfaction (Faymonville et al., 

1997). Further study is needed to clarify its exact role in the management of postoperative pain. 


Intervention Source of Evidence QE R 

1 Hypnosis was associated with improvements in 

pain and anxiety, reduction in analgesic 

requirements, and greater patient satisfaction 

Faymonville et al., 1997 I B 



Version 1.2 




PHYSICAL MODALITIES 

INTRODUCTION 

Physical modalities, such as TENS, heat, cold, exercise, positioning, 

immobilization/rest, massage and acupuncture, have all been applied 

to provide patient comfort during the perioperative period. Each of 

these techniques has a limited set of indications and often some 

definite contraindications. 

Physical modalities may be beneficial in the treatment of primary 

postoperative pain or in relieving discomfort associated with 

positioning during surgery and immobilization/rest. In general, these 

techniques do not provide the primary means of providing 

postoperative analgesia, but often serve as useful adjuncts that 

augment the effects of other analgesic techniques or decrease the 

amount of medications required to provide analgesia. 

There are many postoperative pain settings in which the use of 

physical modalities has not been examined. However, their ability to 

contribute to the patient’s general well being, facilitate exercise in the 

perioperative period and their lack of systemic side effects means that 

they should be considered whenever they are available. Expanded 

use and future research will help to better define their application for 

perioperative pain control in the future. 


Version 1.2 



TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) 

TENS is a method of producing electro-analgesia through the spinal cord gating mechanism. An electrical 

impulse is conducted through electrodes applied to the skin. TENS has been used as an effective adjunct 

for providing postoperative pain control. TENS facilitates movement and exercise by decreasing pain 

perception and improving physical functioning (Wall & Melzack, 1989; Bonica, 2001). 

Advantages: 

• Relatively rapid onset (30-60 minutes) 

• Patient-controlled features 

• Absence of appreciable side effects 


• Requires special equipment 

• Requires skilled personnel for patient instruction 

• May cause burns if used inappropriately 

• May cause skin irritation 


• Requires the active involvement, understanding and cooperation of the patient 


• Cognitive impairment 

• Should not be used near demand-type cardiac pacemakers, over a pregnant uterus, carotid sinus, 

laryngeal or pharyngeal muscles, or around the eye 



1 TENS is effective for pain management in 

postoperative conditions. 

Gersh, 1992 

Carroll et al., 1996 

Mannheimer & Lampe, 

1984 

III 

III 

III 

III 

A 

C 

A 

A 

2 TENS is effective over incision sites. Tyler et al., 1982 III B 

3 TENS is effective for hand operations. Bourke et al., 1984 III A 

4 TENS is effective for thorocotomy. Warfield et al., 1985 III A 

5 TENS is effective for oral facial pain. Hansson et al., 1986 III A 

6 TENS is effective for abdominal pain. Hamza et al., 1999 

Chen et al., 1998 

Hymes et al., 1974 

Cooperman et al., 1977 

Ali et al., 1981 

I 

I 

I 

I 

III 

A 

A 

B 

B 

A 

7 TENS is effective for post-cesarean section. Smith et al., 1986 III A 


Version 1.2 




8 TENS is effective for pain for total hip 

Pike, 1978 III A 

replacements. 

9 TENS is effective for knee replacements. Sabile & Mallory, 1978 I B 

10 TENS is effective for shoulder pain. Bruzga & Speer, 1999 III B 

11 TENS is effective for pain from cholecystectomy. Rosenberg et al., 1978 I A 

12 TENS is effective for pain from lumbar spine. Solomon et al., 1980 III A 

13 TENS is effective for pain from foot surgery. Cornell et al., 1984 I B 

14 TENS is effective for use in combination with 

exercise for pain. 

Harvie, 1979 II-2 A 



Version 1.2 



COLD 

Cold, or cryotherapy, is the application of cold for therapeutic effects. Cooling agents may include cold 

packs, cold baths, vapocoolant sprays, cold compression, continuous-flow cold therapy, and ice massage. 

Cold alters the pain threshold, reduces local swelling, decreases tissue metabolism and/or bleeding, and 

decreases muscle spasm and spasticity (Wall & Melzack, 1989; Bonica, 2001). 

Advantages: 

• Easy to apply 


• Prolonged exposure may cause injury 

• Patient discomfort 

• Can be complicated to apply 


• Use with caution in patient with sensory deficit (e.g., neuropathy, spinal cord injury) 


• Decreased level of consciousness 

• Patient’s inability to provide feedback about his/her tissue temperature 

• Hypersensitivity to cold (i.e., Raynaud’s phenomenon) 

• Marked hypertension 

• Arteriosclerosis 

• Diminished circulation 



1 Can increase pain threshold, reduce local swelling, 

decrease tissue metabolism and/or bleeding, and 

decrease muscle spasm and spasticity. 

Wall & Melzack, 1989 

Bonica, 2001 

III 

III 

A 

A 

2 Effective for knee pain. Barber et al., 1998 

Brandsson et al., 1996 

Webb et al., 1998 

Lessard et al., 1997 

Brown, 1996 

Cohn et al., 1989 

Levy & Marmer, 1992 

Healy et al., 1994 

I 

I 

I 

I 

III 

I 

I 

I 

A 

A 

B 

B 

B 

B 

A 

A 

3 Effective for shoulder pain. Speer et al., 1996 

Bruzga & Speer, 1999 

III 

III 

A 

B 

4 Effective for perineal pain. Steen et al., 2000 I A 

5 Effective for incisional pain. Hargreaves & Lander, 

1989 

I 

A 


Version 1.2 




6 Effective for dental pain. Bastian et al., 1998 I A 

Melzack, 1980 

I A 

7 Effective for thoracotomy. Seino et al., 1985 III A 

8 Use is recommended as an adjunct to other 

treatments, especially compression. 

Moore & Cardea, 1977 

Basur et al., 1976 

III 

III 

A 

A 



Version 1.2 



HEAT 

Heat can usually be initiated 48 hours following the operation, and is commonly used in combination with 

other treatments (AHCPR,1992). Thermal agents are used to apply heat superficially or as deep heating 

applications. Superficial methods include hot packs, warm whirlpools and paraffin. Deep heat, such as 

ultrasound, can increase the temperature of the tissues three to five centimeters in depth (Wall & Melzack, 

1989; Bonica, 2001). 

Advantages: 

• Induces relaxation 

• Decreases joint stiffness, muscle spasm, and guarding 

• Assists in increasing range of motion 

• Increases superficial circulation 


• Increased swelling or bleeding at surgical site when applied 

• Prolonged exposure may cause injury or burns. 


• Monitor patient’s physical response. 

• Use with caution in patient with sensory deficit (e.g., neuropathy, spinal cord injury). 

• Use of deep heat, such as ultrasound, can increase the temperature of tissues three to five 

centimeters in depth. 



• Inability to provide feedback about tissue temperature 

• Acute injuries less than two days 

• Inflammation 

• Superficial or skin infection 

• Hemorrhage 

• Over site of malignancy 

EVIDENCE 


1 Technique should be initiated 48 hours following 

the operation and used in combination with other 

treatments. 

AHCPR, 1992 III A 



Version 1.2 



EXERCISE 

Exercise may include active or passive range of motion, continuous passive motion machine (CPM), active 

exercise, bed mobility, or ambulation, e.g., getting out of bed and walking to the bathroom. Exercise can 

increase or maintain range of motion, increase blood flow, and prevent muscle guarding, spasms, and 

contractures (Wall & Melzack, 1989; Bonica, 2001). 

Advantages: 

• Assists with edema management 

• Reduces risk of venous thrombosis after surgery (Mc Nally et al., 1997; Sochart et al., 1999) 


• May require patient education and instruction by skilled staff 

• May require the use of assistive devices, e.g., walkers, crutches, etc. 


• Effectiveness could be limited by weight bearing status. 

• Exercise may cause exacerbation of existing postoperative pain. 

• Patient with motor blockade from other therapies may need assistance. 


• Immobilization 

• Extremity with known deep venous thrombosis should not be exercised. 



1 Exercise reduces the risk of venous thrombosis after 

surgery. 

Mc Nally et al., 1997 

Sochart & Hardinge, 

1999 

I 

I 

A 

B 

2 Effective for management of knee pain. Campbell, 1990 

Brown, 1996 

Morris, 1995 

McCarthy et al., 1993 

Smidt et al., 1990 

Walsh, 1980 

Paulos et al., 1980 

Andrews, 1980 

Coutts et al., 1989 

III 

III 

III 

I 

III 

III 

III 

III 

III 

B 

B 

C 

A 

C 

A 

A 

A 

B 

3 Effective for shoulder pain. Bruzga & Speer, 1999 III B 

4 Effective for discectomy pain. Danielson et al., 2000 

Deyo, 1983 


I 

III 

A 

B 


Version 1.2 



POSITIONING 

Positioning is used to support or assist the patient. It may be accomplished with pillows, wedges, supports, 

specialty beds, and weight shifting. Repositioning increases blood flow and prevents muscle guarding and 

spasms, which reduces acute pain or prevents additional pain (Lerner et al., 1998). 

Advantages: 

• Prevents formation of decubitus ulcers 

• Prevents pressure injuries and contractures 


• May require specialized equipment 


• Repositioning should be done every two hours (AHCPR, 1992), with assistance if necessary. 


• Necessity for immobilization 

EVIDENCE 


1 Technique should be done every two hours, with AHCPR, 1992 III A 

assistance if necessary. 

QE-= Quality of Evidence; R = Recommendation (See Appendix A) 


Version 1.2 



IMMOBILIZATION/REST 

Patients may be immobilized, as in casting, traction, or prescribed bed rest. Immobilization facilitates the 

healing process after the operation, but is not recommended as a sole intervention for pain control. An 

example of immobilization would be for a fracture, rest, or back surgery. Immobilization may reduce 

edema. 

Advantages: 

• May assist in the healing process and prevent further trauma to an area 


• Increased risk for deep venous thrombosis 

• Extended use of rest, without mobilization, may lead to stiffness, contracture, atrophy, weakness, 

pneumonia, thrombophlebitis, or increased pain. 

• Potential for pressure ulcers 


• Bed rest may be indicated for a limited time period, less than two days (Quebec Task Force, 1981; 

Deyo, 1983). 

EVIDENCE 


1 Bed rest Quebec Task Force, 1981 II-2 E 

2 Limited period of time, less than two days. Deyo, 1983 III B 



Version 1.2 



MASSAGE 

Massage is the repetitive movements of the therapist’s hands or the use of devices such as effleurage, 

petrissage, tapotement, and friction. A medium may be used on the skin such as lotions, oil, powder or ice. 

Massage may be used to stretch muscle length and is usually used in combination with other treatments 

(Wall & Melzack, 1998; Bonica, 2001). 

Advantages: 

• Effective in general pain management (Quebec, 1981; Jurf et al., 1993; Heffline, 1990) 

• Mechanically assists in venous and lymphatic flow 

• Improves skin integrity and mobility 

• Desensitizes tissue 

• Provides comfort and psychological support 


• Personnel and time intensive 

Contraindications: (Relative) 

• Skin graft 

• Hematoma 

• Infection 

• Malignancy 

• Pleural effusion 

• Liver or kidney disease 

• Congestive heart failure 

• Carotid disease 

• Deep venous thrombosis 

EVIDENCE 


1 Massage is beneficial as adjunct treatment for 

general pain management. 

Quebec Task Force, 1981 

Jurf & Nirschl, 1993 

Heffline, 1990 

II-2 

III 

III 

E 

C 

C 



Version 1.2 



ACUPUNCTURE 

Acupuncture might be considered an option in control of postoperative pain in general (National Institutes 

of Health, 1997). 

• Pre-emptive use of acupuncture during standard anesthesia had no effect on postoperative pain 

following knee arthroscopy (Gupta et al., 1999). Complementary therapy using acupuncture in 

combination with conventional pharmacological interventions may lower the need for medication 

and reduce the risk for side effects from these drugs (NCCAM, 1999). 

Adverse reactions to acupuncture are rare. However, serious side effects have been reported, and treatment 

should be administered by a medically trained and licensed acupuncture practitioner (Rosted, 1997). 

Advantages: 

• Relief of postoperative nausea and vomiting 

• Relief of postoperative dental pain 


• Complications associated with improper needle use and management, e.g., self-manipulation of 

needle, broken needle 

• Few RCTs to clarify the definitive role of acupuncture in the management of acute postoperative 

pain 


• Use of proper infection-control measures 

• Administration by a medically trained and licensed acupuncture practitioner 


Absolute: 

• Patient refusal 

• Anticoagulation 


• Infection at site 

• Pacemaker (for electro-acupuncture [Rosted, 1997]) 

Relative 

• Cognitive impairment 

• Bleeding disorder 

• Patient fear of needles 

DISCUSSION 

There are few RCTs on the role of needle acupuncture in the management of postoperative pain. Even with 

respect to control of dental pain following surgery, the data are conflicting (Mayer, 2000). The consensus 

statement, based on clinical experience and limited research data, indicated that acupuncture could be 

considered a treatment option in postoperative pain (National Institutes of Health, 1997). This has been 

shown in pain relief following ablation and auxiliary lymphadenectomy in patients with breast cancer. In 

this study, patients also had increased range of arm motion without pain when compared with controls (He 

et al., 1999). 


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Acupuncture is considered a safe therapeutic modality with rare serious side effects and complications. In 

a review of complications published between 1965-97 (Rosted, 1997), many of the complications were 

avoidable. For example, complications are associated with: 

• Self-insertion of needles 

• Migration of broken needles 

• Infection due to length of time the needle is in place 

• Self-manipulation of needles 

• Use of improper infection control measures 

• Electroacupuncture in the setting of a pacemaker 

• Improper technique in the use of excessively long needles 

• Inaccurate needle placement 

• Lack of medical training of the acupuncturist including knowledge of anatomy 

In the United States, the FDA has addressed the issue of safety in the approval of acupuncture needles for 

use by licensed, registered or certified practitioners and manufacturing standards to include sterility of the 

product and approval for single use only. A listing of medical acupuncturists for each state can be obtained 

through the American Academy of Medical Acupuncture at http://www.medicalacupuncture.org/ 

EVIDENCE 


1 May reduce nausea and vomiting if used in early NIH, 1997 

III B 


Mayer, 2000 

III B 

2 Acupuncture, in combination with 

pharmacological interventions, may lower the 

need for medication and reduce the risk for side 

effects from these drugs. 

NCCAM, 2001 III C 





OPTIONS FOR POSTOPERATIVE PAIN MANAGEMENT: 

PHARMACOLOGIC MANAGEMENT 

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Pharmacologic Management 

How to use this section: 

This section of the guideline includes information and recommendations about medications used in acute 

pain management. The pharmacologic options for pain control include four major classes of medications. 

Preceding the classes of medication is an overview of routes of administration commonly used in 

postoperative pain management. 

This section is organized in the following sequence to facilitate efficient reference by the clinician: 

A. Overview of the routes of administration commonly used in applying medication for pain control 

B. Opioids 

C. Acetaminophen and NSAIDs 

D. Local anesthetics 

E. Glucocorticoids 

The information about each of the medication classes includes the following: 

• Overview of the medication class 

• Summary table for site-specific indications for pain management for the medication class 

• Mechanisms of action, contraindications and considerations 

• Specific agents, detailing dosing and pharmacokinetic information 

• Drug interactions 

• List of references 

Pharmacologic Management Page 1

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ROUTES OF ADMINISTRATION 

ORAL 

Oral (PO) medication is the most common method of pain control. The advantages of safety, simplicity, 

ease of administration, and economy can be overwhelmed by the needs of the postoperative patient 

requiring application of more advanced techniques. 

Advantages: 

• Ease of delivery; patient can self-medicate 

• Can continue at home—longer term 

• Tablet or liquid application 

• Simple and easy to understand 


• More likely for clinician to under-dose 

• Patient must be able to absorb the medication 

• Slower onset 

• Harder to titrate 


• Because this route requires absorption through the gastrointestinal (GI) tract, it may not be 

appropriate for patients with difficulty swallowing or with airway obstruction. 


• Allergy to the medication being used 

• Medication incompatibility 


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INTRAMUSCULAR (IM) 

The most common use of IM pain control is for patients who are hospitalized for major surgical 

procedures, or for outpatients prior to discharge. This technique is successfully used to control moderate to 

severe pain in all regions of the body. Commonly used IM medications include NSAIDS, opioids, mixed 

opioid agonist-antagonists and opioid-antihistamine combinations. 

IM has been the most common route of administration for postoperative pain. Due to the variable 

absorption and the time and staff necessary to administer, other routes are preferred. Ideally, patients with 

moderate to severe postoperative pain should receive pain medication through the IV route. 

Advantages: 

• More rapid onset 

• Works for people who can’t self-medicate or take oral medication 


• Variable absorption 

• Labor-intensive 

• Pain on injection 


• Patients receiving IM are also at risk of peripheral nerve injury. 

• Possible infection or sterile abscess 


• Patients with known bleeding disorders (relative) or those who are being actively anticoagulated 

(absolute) 



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INTRAVENOUS (IV) 

IV drug administration has distinct advantages over other routes of administration, providing better efficacy 

at lower doses. 

Advantages: 

• Wide variety of medications available 

• Reliable delivery with 100 percent rapid absorption 

• More rapid onset and increased potency, allowing for decreased total drug dose 


• Requires the presence of an IV catheter 

• Requires a qualified individual to deliver the drug 

• Needs appropriate monitoring and is highly labor-intensive 

• Relies on a qualified caregiver to administer the dose. This can result in use of relatively larger 

doses that produce side effects, including excessive sedation alternating with periods of inadequate 

analgesia. 

• Associated with anxiety on the part of the patient who wonders when the provider will return to 

deliver more medication 


• Inappropriate dose 

• Medication toxicity/side effects 




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INTRAVENOUS PATIENT CONTROLLED ANALGESIA (IV PCA) 

The development of IV PCA has advanced the delivery of IV medications. Patients are capable of selfadministering 

drugs in adequate doses that produce better pain control. 

Advantages: 

• Higher patient satisfaction 

• Decreased drug use 

• Decreased side effects 

• Decreased labor-intensity 

• Allows the provision of low dose basal infusion to minimize the return of pain while patients are 

sleeping 


• Requires the presence of a functioning IV 

• Requires knowledgeable staff to program it 

• Requires an IV PCA device 


• Overdose 

• Delivery of the wrong drug, replacing a medication cartridge with the wrong concentration or misprogramming 

the device 

• Patient misuse 

• Use by someone other than the patient that may result in excessive dosage beyond the patient’s 

requirement 

• Basal infusion for IV PCA is optional. Some evidence exists that a basal infusion offers no 

advantages and may increase adverse effects; routine use of basal infusions are not recommended 

for acute pain management by some authors. 


• Patients with mental or physical inability to activate the device (absolute) 

• Patients with reluctance to assume responsibility over analgesic administration (relative) 



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REGIONAL 

Regional analgesia is a preferred method of providing postoperative pain control to a specific area of the 

body. This technique can also be used as the anesthetic for the operation either solely or in combination 

with other anesthetic techniques. Regional analgesia ranges from local wound or joint infiltration to 

specific peripheral nerve blocking techniques affecting specific regions of the body. Examples include: 

interscalene block, lumbar plexus block, Bier’s block, intercostal block, paravertebral block, ankle block, 

sciatic nerve block, popliteal block, and incisional infiltration. 

Patient outcomes are improved with better pain control using these techniques compared to other methods 

of pain control. The role of regional anesthesia/analgesia in the production of preemptive analgesia 

remains controversial. Several clinical studies have demonstrated benefit in the perioperative period 

following regional anesthesia/analgesia initiated prior to surgical incision. These benefits include 

decreased pain immediately after the operation and well into the recovery period. Some of the beneficial 

effects may last beyond the duration of the anesthetic/analgesic technique. 

Advantages: 

• Allows for decrease in, or elimination of, systemic analgesics by limiting the analgesia to a region 

of the body 

• Allows for earlier discharge of ambulatory surgery patients due to the minimized use of systemic 

analgesics (opioids) improved pain control, and decreased incidence of associated side-effects. 

These techniques can be done as a single injection or continuously. 


• Requires knowledgeable providers capable of performing a wide variety of techniques in a reliable 

and timely manner 

• Limited duration of action if a single administration is used—patients may require a combination 

of other modalities 

• Requires specialized equipment 

• Produces a short period of irreversibility, limiting physical examination 


• Block failure to provide analgesia 

• Local anesthetic toxicity 

• Injection of medication intravascularly, epidurally, or intrathecally leading to respiratory 

compromise or cardiovascular collapse 

• Bleeding 

• Hematoma 

• Neurologic injury 

• Pneumothorax 

• Organ injury 

• Infection 


• Patient refusal to undergo procedure (absolute) 

• Failure to obtain consent (absolute) 

• Patients who are anticoagulated (absolute) 

• Infection at the site of proposed needle insertion (absolute) 

• Allergy to medication being used in technique (absolute) 

• Altered anatomy (relative) 

• Bleeding disorders (relative) 

• Inability to communicate (relative) 

• Patients with peripheral neurologic diseases (relative) 


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EPIDURAL 

Epidural is one of the techniques used to provide regional anesthesia/analgesia. It is widely used and 

accepted, but requires skilled providers and institutional commitment for optimal benefit. Epidural 

technique can improve analgesia using decreased doses of opioids to provide equal analgesia as compared 

with IM, PO, and IV, because medication is delivered to opioid receptors in the dorsal horn of the spinal 

cord. 

Advantages: 

• Places medication near site of action 

• Decreases side effects 

• Can be used as the anesthetic for the operation 

• Provides improved active pain control with movement as compared to other techniques. This is 

especially true when local anesthesia is used and the catheters are placed at the appropriate level of 

the incision (e.g., thoracic epidural for thoracotomy). 

• Increases blood flow below the level of analgesia; may improve graft survival 

• Is usually a continuous technique 

• Improves return of bowel function 

• Can be used for extended periods of time postoperatively 


• Requires knowledgeable and competent providers to perform procedure in a reliable and timely 

manner 


• Requires high-level supervision and monitoring 

• If local anesthesia is used with epidural infusion, it may produce weakness from unwanted motor 

blockade, hypotension, or urinary retention that may require bladder catheterization. 

• If opioids are used in epidural infusion, they may produce sedation or respiratory depression, 

nausea, vomiting and pruritis. 

• Interference with neurologic monitoring 


• Post-dural puncture headache 

• Infection, including meningitis 

• Epidural hematoma with risk of paralysis 

• Arachnoiditis 

• Respiratory compromise and cardiovascular collapse with overdose 

• Inadvertent administration of inappropriate medication (drugs that should not be in the spinal 

canal) 


• Allergy or medication toxicity (absolute) 


• Patient refusal (absolute) 

• Anticoagulated patient (absolute) 

• Infection at site (absolute) 

• Hemodynamic instability (relative) 

• Prior spinal surgery at site of insertion (relative) 

• Spinal column abnormality (relative) 


• Compromised cardiac function (relative) 



• Systemic infection (relative) 


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SPINAL 

Spinal administration is one of the techniques used to provide regional anesthesia/analgesia. It is widely 

used and accepted; however, it is not recommended as a continuous technique for postoperative pain 

management due to inherent risks involved. 

Advantages: 

• Improved analgesia with decreased dose of opioids to provide equal analgesia as compared with 

IM, PO and IV 

• Places medication near site of action 

• Decreases side effects 

• Can be used as the anesthetic for the operation 

• May be used as a single administration or continuous technique 


• Requires knowledgeable providers 

• Needle and/or catheter insertion is limited to the lumbar region due to the risk of potential spinal 

cord injury during insertion. 

• Needs to be done in both a reliable and timely manner 


• Requires high-level supervision and monitoring 

• If local anesthesia is used with spinal infusion it may produce weakness from unwanted motor 

blockade, hypotension, urinary retention that may require bladder catheterization. 

• If opioids are used in spinal infusion they may produce sedation or respiratory depression, nausea, 

vomiting and pruritis. The duration of catheter insertion is limited due to the risk of developing 

meningitis. 


• Post-dural puncture headache 

• Infection including meningitis 

• Subarachnoid hematoma with risk of paralysis 

• Arachnoiditis 

• Respiratory compromise and cardiovascular collapse with overdose 

• Inadvertent administration of inappropriate medication 

• Drug toxicity producing permanent neurologic deficit, incorrect drug administration in the 

presence of continuous spinal catheters 

• Spinal cord or nerve injury 


• Allergy or medication toxicity (absolute) 

• Patient refusal (absolute) 


• Anticoagulated patient (absolute) 

• Infection at site (absolute) 

• Hemodynamic instability (relative) 


• Prior spinal surgery at site of insertion (relative) 


• Spinal column abnormality (relative) 

• Compromised cardiac function (relative) 


• Systemic infection (relative) 


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OPIOIDS 

Opioid agents are the mainstay of postoperative analgesia. They offer safe and effective pain control and 

are typically used in the treatment of moderate to severe pain. Pain management with these agents should 

be individually tailored to patient response. There is no ceiling dose for pure agonist opioids. 

Opioids should be administered by the safest and most effective route available. These agents can be used 

safely in conjunction with other analgesic agents and by various administration techniques. In comparison 

with conventional methods of administration (e.g., intermittent IM or SC injections), contemporary 

delivery systems (e.g., PCA) and techniques (e.g., neuraxial) help to improve postoperative pain control 

and patient satisfaction. The route of administration may vary throughout the peri-operative period. When 

selecting an appropriate route, consideration must be given to the patient’s overall condition and the 

availability of specialized equipment and trained staff. The availability of these resources may vary 

between institutions. 

Opioids have significant adverse effects that can be managed by modification of dose, route, or adjunctive 

agents. Respiratory depression should not be a concern if the appropriate dose, route, and dosing frequency 

are used with adequate patient monitoring. 

The Working Group does not recommend the use of meperidine for postoperative pain management. 

Longer-acting and safer alternatives to meperidine exist. Meperidine has a relatively short duration of 

action and the potential for underdosing; the risk of inadequate pain management is greater with its use. 

Regular dosing or high doses in patients with normal or impaired renal function may result in accumulation 

of normeperidine, a neurotoxic metabolite, which may cause seizures. It is difficult to identify patients at 

risk for meperidine-induced seizures. If meperidine is indicated (e.g., for the rare patient with 

hypersensitivity to opioids from another class), its use should be restricted to the recovery room or limited 

to less than 24 hours in doses less than 600 mg / 24 hours. 

Key points 

• Opioids produce their analgesic effects by mimicking the actions of endogenous opioid peptides at 

specific opiate receptor sites in the central nervous system. 

• Physiologic effects of opioids include the following: 

- Respiratory effects 

- Gastrointestinal effects 

- Cardiovascular effects 

- Genitourinary effects 

- Physiologic dependence 

- Tolerance 

• Evidence indicates that there is no significant risk of addiction with short term use of opioids for 

postoperative pain management. Addiction is often a concern of patients and should be addressed 

preoperatively. 

• Routes of opioid administration for postoperative pain include the following: 

- Conventional (IV / IM / SQ / PO / PR) 

- Patient controlled analgesia (PCA) 

- Neuraxial (spinal/epidural) 

- Novel (e.g., transmucosal) 

• Commonly used opioids in postoperative pain include agents in the following classes: 

- Pure agonists 

- Morphine, hydromorphone 

- Meperidine, fentanyl 

- Codeine, oxycodone, and hydrocodone (e.g., in combination with acetaminophen) 

- Mixed agonists-antagonist opioid analgesics 

Pharmacologic Management: Opioids Page 9

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DISCUSSION 

Mechanism of opioid action and receptor types 

Opioids produce their analgesic activity by mimicking the actions of endogenous opioid peptides at specific 

opiate receptors in the central nervous system (CNS). Endogenous opioids all contain the amino acid 

sequence tyr-gly-gly-phenyl. They include metenkephalin, beta-endorphin, and dynorphin. The three main 

types of opiate receptors, each with its own subtypes, are mu (µ, µ 1 and µ 2 ), delta (δ, δ 1 and δ 2 ), and kappa 

(κ, κ 1-4 ). 

Most commonly used opioids, for example morphine and codeine, bind to the µ receptor. Activation at the 

µ 1 receptor is responsible for supraspinal analgesia, whereas µ 2 -receptor activation leads to the undesired 

effects of respiratory depression, cardiovascular depression, and decreased gastrointestinal motility. 

• The enkephalins are the primary endogenous ligands of the δ receptor and are primarily 

responsible for spinal analgesia. Enkephalins are found in areas not only known to be involved 

with nociception but also in the gastrointestinal (GI) tract, sympathetic nervous system, and 

adrenal medulla. 

• Dynorphin is the prototypic ligand for the κ receptor. Activation of the κ receptor results in 

segmental spinal analgesia and sedation. Most of the mixed agonist-antagonist opioids (e.g., 

butorphanol) bind to the κ receptor. 

Physiologic effects of opioids 

Respiratory effects 

All opioids depress minute ventilation by depressing the response of the brain to carbon dioxide. Opioids 

primarily reduce respiratory rate, although in high doses they can also depress tidal volumes. Respiratory 

depression, apnea and even death may occur. However, when prescribed and administered for pain in a 

properly monitored patient, opioids rarely cause respiratory depression. Fear of inducing respiratory 

depression should never be used as a reason to avoid treating pain. Opioids are also potent antitussives. 

Gastrointestinal effects 

Opioids universally decrease GI motility by reducing peristalsis in the small intestine and large intestine, 

and by increasing tone in the pyloric sphincter, ileocecal valve, and anal sphincter. Thus, opioid use is 

associated with constipation. These agents were first used for the treatment of diarrhea (dysentery). When 

these agents are prescribed for longer than 1 or 2 days, stimulant laxatives and stool softeners are 

necessary. Unlike other opioid-induced adverse effects, tolerance to constipation does not develop over 

time. 

All µ-agonist opioids, including meperidine, can cause spasms of the sphincter of Oddi. This effect can be 

problematic in patients with pancreatitis, cholelithiasis, or sickle cell disease. 

Opioids are also associated with nausea and vomiting, which are caused by the binding of opioids to 

receptors in the chemoreceptor trigger zone of the brainstem and by slowed GI motility. Drug treatment of 

nausea and vomiting differs according to the cause. If caused by stimulation of the chemoreceptor trigger 

zone, ondansetron, prochlorperazine, thiethylperazine or haloperidol may be helpful. If caused by slowed 

GI motility, metoclopramide may be helpful. Nalbuphine (a mixed opioid agonist-antagonist) or a lowdose 

infusion of naloxone (an opioid antagonist) are also useful in the treatment of nausea and vomiting. 

For nausea associated with motion (often accompanied by vertigo), dimenhydrinate may be helpful. 

Scopolamine patches are sometimes used for nausea associated with motion but may cause confusion. 


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Cardiovascular effects 

Opioids have few hemodynamic adverse effects. They do not affect the contractile state of the heart or 

alter cardiac output. All opioids can cause dose-dependent, asymptomatic bradycardia, with the exception 

of meperidine, which produces tachycardia. Morphine is a vasodilator and venodilator. It affects preload 

and afterload by relaxing vascular smooth muscle and by releasing histamine from mast cells. These 

actions may produce hypotension, especially in hypovolemic (e.g., trauma) patients. Histamine release 

occurs to a lesser extent with codeine and meperidine, and not at all with hydromorphone, fentanyl, 

sufentanil or remifentanil. The hypotensive effects of the opioids can be minimized by slow infusion, 

keeping patients supine, and maintaining an adequate intravascular volume. 

Genitourinary effects 

Opioids increase the tone of the detrussor muscle of the bladder and may cause urinary retention, which 

may require bladder catheterization. This adverse effect may occur regardless of the route of opioid 

administration but is more common after neuraxial administration. 

Physiologic dependence 

Sudden cessation of opioid medication after continued therapy may lead to the development of abstinence 

syndrome or withdrawal. Symptoms include tachycardia, lacrimation, yawning, sneezing, coryza, nausea, 

vomiting, hypertension, restlessness, and insomnia. Physiologic dependence can develop after only 5 days 

of therapy. Symptoms typically occur within 24 hours and peak about 72 hours after discontinuation of 

opioid therapy. Tolerance and withdrawal seem to be linked. Note the difference between physiologic 

dependence and addiction, which is a behavioral effect of opioids (see below). 

Tolerance 

Continued exposure to opioids often results in the need for higher doses to achieve the same clinical effect. 

This phenomenon is known as tolerance and usually begins within 21 days after beginning opioid therapy. 

Shorter-acting, more lipophilic agents, such as fentanyl, may lead to tolerance faster than longer-acting, 

hydrophilic agents, such as morphine. On the other hand, results from animal studies suggest that tolerance 

develops less frequently with opioids that have high receptor affinity, such as sufentanil. 

Some degree of cross-tolerance occurs between opioids, although it is incomplete. Patients who are 

becoming tolerant to morphine may benefit from a change to a drug with increased binding affinity, such as 

hydromorphone. Tolerance develops more quickly when continuous infusions, rather than intermittent 

boluses, are used. 

Behavioral effect of opioids (addiction) 

Addiction is defined by the World Health Organization as “A state, psychologic and sometimes also 

physical, resulting from the interactions between a living organism and a drug, characterized by behavioral 

and other responses that always include a compulsion to take the drug on a continuous or periodic basis in 

order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance 

may or may not be present.” Addiction is a psychiatric disorder associated with excessive self-medication 

against medical advice and compulsive, often criminal, acquisition of drug. It should not be a concern for 

the acute postoperative patient receiving opioids for a short, determinable period. 

Commonly used opioids in postoperative pain 

The opioids commonly used in the treatment of postoperative pain can be classified as pure agonists or 

mixed agonist-antagonists. A pure agonist has maximal physiologic effect at the binding site (e.g., 

morphine). An antagonist occupies the site but has no physiologic action (e.g., naloxone). A partial 

agonist occupies the site but has submaximal physiologic activity even at high doses (e.g., buprenorphone). 

A mixed opioid agonist-antagonist has agonist effects at some receptors and antagonist effects at others 


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(e.g., nalbuphine). Tramadol is a centrally acting synthetic analgesic chemically unrelated to opiates; 

however, it is also considered to be an opioid because of its agonist activity at µ receptors. 

Pure agonists 

1. Morphine 

Morphine is the gold standard against which all other opioids are compared. It is the most widely used 

opioid for the management of acute pain in adults. Morphine is hydrophilic and does not cross the bloodbrain 

barrier well. It also has poor oral bioavailability (20% to 30%), which necessitates a larger oral (PO) 

dose when converting from parenteral to enteral routes of drug administration. In addition to PO, 

intravenous (IV), intramuscular (IM), and subcutaneous (SC) routes, morphine can be administered by 

epidural and intrathecal routes using preservative-free formulations. Morphine is metabolized in the liver 

by microsomal mixed-function oxygenases that require the P-450 system. Two metabolites are morphine- 

6-glucuronide (which is active and more potent than morphine) and morphine-3-glucuronide (which is 

inactive but competes competitively with morphine at binding sites). These metabolites are excreted 

renally, so morphine (and opioids that are metabolized to morphine, e.g., codeine) must be used with 

caution in patients with renal failure because the active metabolite accumulates in the blood. Morphine 

induces histamine release and must be used carefully in patients with asthma or atopy. Histamine release 

also causes vasodilatation and may produce hypotension in hypovolemic patients. 

2. Meperidine 

Meperidine has one-tenth the analgesic potency of morphine and may have a shorter duration of analgesia 

(2 to 4 h vs. 2 to 7 h for morphine IM). At equipotent doses, it has an adverse effect profile similar to that 

of morphine. It offers no advantages over morphine in terms of sphincter of Oddi spasms, bowel motility, 

or respiratory depression. Meperidine produces a “rush” or euphoric feeling that some patients enjoy and 

thus label meperidine as the “most” effective opioid for them. 

The primary metabolite of meperidine, by hepatic N-demethylation, is normeperidine. This compound has 

half the analgesic activity of meperidine, is renally eliminated, and can cause hallucinations, agitation, and 

seizures. Regular dosing or high doses in patients with normal or impaired renal function may result in 

accumulation of normeperidine. Seizures can be seen at doses of 10 mg/kg/d IV, IM, or SC. It is difficult 

to identify patients at risk for meperidine-induced seizures. 

Patients who concomitantly take meperidine and monoamine oxidase inhibitor (MAOI) antidepressants 

may develop a potentially fatal drug interaction. Because of the long half-life of MAOIs, patients who 

have discontinued these agents within the previous two weeks are also at risk. The drug interaction may 

cause a serotonin-like syndrome—a life-threatening condition manifested by hyperpyrexia, acidosis, shock, 

and death. 

Because of the toxic metabolite and potentially fatal drug-drug interaction with MAOIs, one should rarely 

prescribe meperidine for acute (or chronic) pain. The Working Group does not recommend the use of 

meperidine in the treatment of postoperative pain; longer-acting and safer opioids are available. If 

meperidine is indicated (e.g., for the rare patients with hypersensitivity to opioids from another class), its 

use should be restricted to the recovery room or limited to less than 24 hours in doses less than 600 mg / 

24 h. 

3. Fentanyl 

Fentanyl is highly lipid soluble, equilibrates rapidly at the effector site, and has no active metabolites. 

Fentanyl can be administered by the IV, IM, SC, transmucosal, and transdermal route. It is most 

commonly used for short, painful procedures; however, it also can be used for postsurgical and burn pain 

relief. In general, a dose of fentanyl, 0.5 to 2.0 µg/kg/h, is appropriate whether given intermittently or by 

continuous infusion. Transdermal fentanyl is contraindicated for acute pain management. 


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4. Hydromorphone 

Hydromorphone is sevenfold to tenfold more potent than morphine, and twofold to sevenfold more lipid 

soluble. It is metabolized to hydromorphone-3-glucuronide, which lacks analgesic effect but has been 

associated with neurotoxicity. The elimination half-life is 2 to 3 hours. It is typically associated with fewer 

adverse effects (e.g., nausea, vomiting, and pruritus) than morphine. Like morphine, it is versatile and can 

be administered by the IV, SC, PO, epidural, or intrathecal routes. 

5. Codeine, oxycodone, and hydrocodone 

Codeine, oxycodone, and hydrocodone are opioids that are commonly used to treat pain in children and 

adults, especially for less severe pain or when treatment is being converted from parenteral opioids to 

enteral ones. Codeine, oxycodone, and hydrocodone are most commonly administered by the PO route, 

usually in combination with acetaminophen or aspirin. About 10% of administered codeine is metabolized 

to morphine, which is responsible for most if not all of codeine’s analgesic and antitussive effects. With 

all combination preparations, physicians should beware of inadvertently administering hepatotoxic doses of 

acetaminophen when increasing doses for uncontrolled pain; all sources of acetaminophen should be 

considered. Acetaminophen toxicity may result from a single toxic dose (e.g., 5.85 g), from repeated 

ingestion of large doses of acetaminophen (e.g., in adults, 7.5 to 10.0 g/d for 1-2 d; in children, 60 to 

420 mg/kg/d for 1 to 42 d) or from chronic ingestion. The recommended maximal daily dose for 

acetaminophen is 4 g/d in adults with normal hepatic function and 2 g/d in chronic alcoholics. 

Mixed opioid agonist-antagonists 

Mixed opioid agonist-antagonists produce analgesia primarily at the κ receptor. They have a ceiling effect 

and produce limited respiratory depression. In patients who are physiologically dependent on opioids, 

these drugs can induce withdrawal symptoms. One of the most useful indications for opioid agonistantagonists 

is treatment of opioid-induced adverse effects, including nausea and vomiting, sedation, and 

pruritus. Opioid agonist-antagonists typically reverse these effects without reversing analgesia. 

Routes of opioid administration for postoperative pain 

1. Conventional (IV / IM / SQ / PO / PR) 

Probably the most common route of administering opioids is by intermittent IM or SC injections. Since IM 

and SC injections of opioids have variable absorption and are painful and time-consuming, one should use 

other routes if possible. Patients with severe postoperative pain should be administered opioids via IV PCA 

(see below) or epidural or intrathecal injections. The PO route, if tolerated, would also be an option but the 

likelihood of under-dosing opioids orally must be considered. 

2. Patient controlled analgesia (PCA) 

The rationale for PCA is the following: as-needed (prn) opioid dosing leads to episodes or cycles of pain 

that in turn lead to as-needed dosing of an analgesic. The episodes of pain that occur between analgesic 

doses lead to increased anxiety. The relatively large doses of opioids used to "rescue" patients typically are 

followed by periods of excessive sedation. PCA uses frequent administration of “mini” doses of analgesics 

initiated by patients, thereby eliminating the peaks and valleys of analgesia and pain. Overall, improved 

patient satisfaction results from the control over analgesic medication. Typically, the total quantity of 

analgesic required is smaller with PCA than conventional as-needed dosing, so less severe and fewer 

adverse effects occur with PCA. Nursing time may also be saved. 

Relative contraindications to PCA include the inability to use the PCA button effectively because of 

physical or cognitive reasons, patient desire not to assume responsibility over analgesic administration, or a 

history of substance abuse. Family members and nurses typically are not permitted to activate the PCA 

device. 


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Institutions that have IV PCA capability have staff members who are knowledgeable in the use of the 

various devices available. They are also able to diagnose and are prepared to manage potential, rare 

complications, including respiratory distress, apnea, and other adverse effects typically seen with opioids. 

The three programmable parameters on most PCA devices are dose, frequency and an optional continuous, 

basal infusion rate. PCA is not limited to the IV route; epidural PCA, PO PCA and SC PCA have all been 

used with success. 

3. Neuraxial (epidural/intrathecal) 

Neuraxial opioids may be administered in the epidural or intrathecal (subarachnoid) space. Delivered at 

these sites, they bypass the blood-brain barrier and require significantly lower doses, typically 1/10 to 1/100 

of the effective IV dose. Epidural and intrathecal opioids are extremely effective for the management of 

severe pain whether it is postoperative, chronic, or malignant in origin. 

Opioids administered in the epidural space must enter the cerebrospinal fluid (CSF) by the dura and pia 

mater, diffuse through the water phase of the CSF, then cross the lipid membranes of the neuraxis to reach 

opioid receptors in the substantia gelatinosa. Hydrophilic agents, such as morphine, demonstrate increased 

latency and duration of action because their water solubility retards diffusion out of the CSF and into the 

substance of the spinal cord. Because of the depot of agent that remains dissolved in CSF, rostral spread of 

the drug is increased. Rostral spread of drug is associated with a small risk of delayed respiratory 

depression, typically 6 to 8 hours after administration. 

Because hydrophilic agents remain in the CSF, uptake into the epidural blood vessels is slow, and the 

administration of epidural hydrophilic opioids is associated with low or undetectable systemic blood levels. 

Thus, water-soluble opioids administered spinally exert their analgesic effect spinally. Lipid-soluble 

agonists, such as fentanyl, have a rapid onset of action and provide segmental analgesia with less rostral 

spread of drug. Lipid-soluble opioids also have a rapid rate of diffusion into the venous plexus of the 

epidural space, resulting in rapid drug removal from the neuraxis and achievement of therapeutic IV blood 

levels. Controversy exists regarding whether epidurally administered lipid-soluble agents, such as fentanyl 

and sufentanil, exert their analgesic effect primarily at the neuraxis or by systemic absorption and 

hematogenous drug delivery to the CNS. 

Neuraxial opioids can be administered by a single bolus injection into the epidural space or CSF or by a 

continuous infusion via an indwelling catheter. No change occurs in autonomic function, and light touch 

sensation and proprioception are preserved. The frequency of urinary retention is increased, mandating 

bladder catheterization in approximately one-third of patients. Other possible adverse effects include 

nausea and vomiting, pruritus, and acute or delayed respiratory depression. 

4. Novel 

Because fentanyl is extremely lipophilic, it can be readily absorbed across any biologic membrane, 

including the skin. Thus, it can be given painlessly by new, non-intravenous routes of drug administration, 

including the transmucosal (nose and mouth) and transdermal routes. Transmucosal fentanyl is extremely 

effective for acute pain relief. For oral-buccal administration using this novel delivery technique, fentanyl 

is manufactured in a candy matrix (Fentanyl Oralet) attached to a plastic applicator (similar to a lollipop). 

As the patient sucks on the candy, fentanyl is absorbed across the buccal mucosa and is rapidly absorbed 

(in 10 to 20 minutes) into the systemic circulation. The major adverse effect is nausea and vomiting, which 

occurs in approximately 20% to 33% of patients who receive it. This product is available only in hospital 

(and surgicenter) pharmacies and, like all sedative-analgesics, requires vigilant patient monitoring. 

When drugs are administered transdermally, a patch with a selective semipermeable membrane and 

reservoir of drug is applied to the skin. The patch allows for the slow, steady absorption of drug across the 

skin. The only opioid currently approved by the Food and Drug Administration (FDA) for transdermal 

application is fentanyl. Transdermal fentanyl is contraindicated for acute pain management and is used 

only for patients with chronic pain (e.g., cancer) or in opioid tolerant patients. The onset of action is 

16 hours after application of the patch, and fentanyl continues to be absorbed from the subcutaneous fat for 


Version 1.2 



almost 24 hours after the patch is removed. These characteristics make it hazardous to use in an acute pain 

setting. 




Summary Table: Site-specific Pain Management Interventions – OPIOIDS 




Ophthalmic OP OP OP -- -- RARELY C X 

Craniotomy OP OP OP -- -- OP 

Radical neck OP OP OP -- -- OP X 

Oral-maxillofacial OP OP OP -- -- OP C, I X 


Thoracotomy OP OP OP OP OP OP C, T X 

Mastectomy OP OP OP OP OP OP C, T X 

Thoracoscopy OP OP OP OP OP OP C, T X 


CABG OP OP OP RARELY OP OP RARELY 

MID-CAB OP OP OP RARELY OP OP X 

Laparotomy OP OP OP OP OP OP E, T X Opioids may impair bowel function 

Laparoscopic cholecystectomy OP OP OP RARELY RARELY OP E, T X Opioids may cause biliary spasm 

Nephrectomy OP OP OP OP OP OP E, T X 


Hysterectomy OP OP OP OP OP OP E, X Opioids may impair bowel function 

Radical prostatectomy OP OP OP OP OP OP -- E X Opioids may impair bowel function 

Hernia OP OP OP RARELY OP RARELY C, X 


Laminectomy OP OP OP RARELY RARELY OP -- C, E X 

Spinal fusion OP OP OP RARELY RARELY OP -- E I X 


Vascular OP OP OP OP OP OP C, E X 

Total hip replacement OP OP OP OP OP OP C, E, T X 

Total knee replacement OP OP OP OP OP OP C, E, T X 


OP OP OP RARELY OP OP C, E, T X 


Amputation OP OP OP OP OP OP C, E, T X 

Shoulder OP OP OP -- -- OP C, E, I, T X 

OP = Opioids; C = Cold; E = Exercise; I = Immobilization; T = TENS; X = Use of cognitive therapy is patient-dependent rather than procedure-dependent 

Indications for Use: Bold/Red/Shaded: Preferred based on evidence (QE=1; R=A); Italicized/Blue: Common usage based on consensus (QE=III); Plain Text: Possible Use 




Table OP1. Opioids: Mechanisms of Action, Contraindications, Other Considerations 

DRUG CLASS MECHANISM OF ACTION CONTRAINDICATIONS OTHER CONSIDERATIONS 

Opioid agonists Agonist activity at opiate receptors Hypersensitivity to specific agent or 

component of the formulation — does not 

preclude use of agent from another 

subclass 

Mixed opioid 

agonistantagonists 

Other 

(Tramadol) 

Agonist effects at some opiate receptors; 

antagonist effects at other opiate 

receptors; ceiling to analgesic effects 

Tramadol and its M1 metabolite are weak 

agonists at µ-opiate reeptors and 

inhibitors of norepinephrine and 

serotonin reuptake; these mechanisms are 

synergistic. 

Acute bronchial asthma 

Upper airway obstruction 

Concurrent or recent use (within previous 

2 weeks or more) of MAOIs with 

meperidine — combination may result in 

potentially fatal drug interaction 

(serotonin-like syndrome). 

Hypersensitivity to any of these agents or 

component of the formulation. 

Physiologic opioid dependence (these 

agents may precipitate withdrawal 

symptoms). 

Hypersensitivity to tramadol or component 

of the formulation. 

Acute intoxication with alcohol, hypnotics, 

centrally acting analgesics, opioids, or 

psychotropic drugs. 

Concurrent use of MAOIs or SSRIs — 

drug interaction may cause serotonin-like 

syndrome. Recent use (within the previous 

2 wk or more) of MAOIs may also cause a 

reaction. 

Opioids may interfere with neurologic evaluation after head trauma or 

neurosurgery. 

All of these agents may increase intracranial pressure; use with caution in 

patients with head injury or increased intracranial pressure. 

Muscle rigidity, typically starting in the upper body and chest, often occurs 

during induction of anesthesia with larger doses or rapid administration of 

opioids. 

Alfentanil and fentanyl may cause temporal lobe activation or seizures in 

patients with complex partial epilepsy (Manninen et al., 1999; Ragazzo et 

al., 2000; Tempelhoff et al., 1992). 

Alfentanil, fentanyl, remifentanil, and sufentanil do not cause histamine 

release (Cambareri et al., 1993; Flacke et al., 1987; Hermens et al., 1985; 

Rosow et al., 1982; Sebel et al., 1995; Warner et al., 1991). 

Meperidine has equivocal effects on biliary spasm and has no clear 

advantage over other opioids. † 

Fatalities have been associated with the use of propoxyphene in patients 

who are actively or previously suicidal, prone to drug addiction, taking 

neuroleptics or antidepressant drugs, using alcohol in excess, or inclined to 

excessive self-medication. 

Lower abuse potential than pure agonists. 

All of these agents may increase intracranial pressure; use with caution in 

patients with head injury or increased intracranial pressure. 

Butorphanol may increase blood pressure and cardiac workload; use only if 

benefits outweigh the risks in patients with cardiovascular disease. 

Buprenorphine, nalbuphine, and butorphanol may cause less biliary 

spasm (McCammon et al., 1984; Staritz et al., 1986). 

Pentazocine tends to cause hallucinations, confusion, or dysphoria. 

Less respiratory depressant effects than morphine. 

Lacks adverse effects on heart rate, left ventricular function, and cardiac 

index. 

Does not cause histamine release. 

Risk of seizures may be increased in the following patients: those taking 

MAOIs, SSRIs, tricyclic antidepressants, neuroleptics, or other drugs that 

reduce seizure threshold; patients with epilepsy; patients with risk factors for 

seizure; or patients who take overdoses of tramadol (≥ 500 mg PO) (Gardner 

et al., 2000; Gasse et al., 2000; Jick et al., 1998; Spiller et al., 1997). 




Table OP1. Opioids: Mechanisms of Action, Contraindications, Other Considerations 

MAOI = Monoamine oxidase inhibitor; SSRI = Selective serotonin reuptake inhibitor 

† 

There is no convincing evidence that meperidine is associated with less biliary spasm than other opioids. Some studies have found a detrimental effect (Joehl et al., 1984; Radnay et al., 

1984) and others, a lack of effect on bile duct pressure, biliary clearance, or biliary contractions (Elta et al., 1994; Thune et al., 1990). Agents shown to have a lower likelihood of 

inducing biliary spasm are tramadol and the agonist-antagonist opioids, including buprenorphine, nalbuphine, and butorphanol (McCammon et al., 1984; Staritz et al., 1986) 




Table OP2. Opioids: Dosing and Pharmacokinetics 

OPIOID AGENT † 

ROUTE 

INITIAL DOSAGE REGIMEN 

[TYPICAL DOSAGE RANGE] 

FOR 70-KG ADULT 

(18 TO 65 Y) 

PURE AGONISTS 

Phenanthrenes 

Codeine PO 30 mg [15 to 60 mg] q 4 to 6 h 

(Max. 360 mg/d; 

for combinations with 

acetaminophen, max. 4 g/d 

acetaminophen) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

15 to 30 

30 to 60 

4 to 6 

IM same as PO — 

IV 15 to 30 mg q 2 h — 

SC same as PO 15 to 30 

— 

4 to 6 

Hydrocodone PO 5 to 10 mg q 4 to 6 h 

(Max. daily dose is 60 mg when 

given in fixed combination with 

acetaminophen, and 37.5 mg 

when given in fixed combination 

with ibuprofen) 

15 to 30 

30 to 60 

4 to 8 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 

Hepatic / Renal 

Metabolized to morphine via CYP- 

2D6 isoenzyme. 

2 to 4 


Metabolized to hydromorphone via 

CYP-2D6 isoenzyme. 

3.3 to 4.5 

DOSING IN SPECIAL POPULATIONS 

AND OTHER CONSIDERATIONS 

• Elderly – Use with caution. 

• Hepatic dysfunction – conversion to active 

metabolite (morphine) may be reduced in 

patients with cirrhosis; avoid use in patients 

with liver disease. 

• Renal dysfunction – use lower dosage or an 

alternative analgesic. 

• May be ineffective in patients with decreased 

CYP-2D6 activity (due to poor CYP-2D6 

metabolism or CYP-2D6 inhibiting drugs) 

because it is not converted to morphine. 

• Elderly (≥ 65 y) – Use with caution, starting at 

low end of dosing range. 

• Hepatic / Renal dysfunction – Use with 

caution. 

• May be ineffective in patients with decreased 

CYP-2D6 activity (due to poor CYP-2D6 

metabolism or CYP-2D6 inhibiting drugs). 






ROUTE 




(18 TO 65 Y) 

Hydromorphone PO 2 mg [2 to 4 mg or 0.04 to 0.08 

mg/kg] q 4 to 6 h 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

15 to 30 

30 to 60 

4 to 6 

IM 1 to 2 mg [2 to 4 mg or 0.04 to 

0.08 mg/kg] q 4 to 6 h 

< 15 

30 to 60 

4 to 6 

IV 0.5 mg [0.5 to 2 mg or 0.01 to < 0.5 

0.04 mg/kg] q 4 h (slowly over 2 5 to 20 

to 3 min.) 

2 to 4 

SC 1 to 2 mg [2 to 4 mg or 0.04 to 

0.08 mg/kg] q 4 to 6 h 

< 15 

30 to 60 

4 to 6 

PR 3 mg q 6 to 8 h — 

— 

6 to 8 

ED § Single dose 0.5 to 1.5 mg 

(0.01 to 0.03 mg/kg) 

Infusion 0.1 to 0.2 mg/h 

PCEA Load 0.5 to 1.5 mg; basal 

infusion 0.08 to 0.12 mg/h; 

demand dose 0.02 to 0.03 mg; 

lockout 6 to 8 min. Bupivacaine 

0.031% often added. ‡‡ 5 to 15 

30 

10 to 16 § 

IT § — 

IV PCA Load 0.1 to 0.5 mg (0.002 to 0.01 

mg/kg); bolus/demand dose 0.1 to 

0.5 mg; lockout 6 to 8 min; basal 

infusion || 0.1 to 0.3 mg/h 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 


Metabolized to 

hydromorphone-3-glucuronide 

(H3G) 

2 to 3 



• Elderly (≥ 65 y) – Use with caution, starting at 

low end of dosing range. 

• Hepatic / Renal dysfunction – Use with 

caution. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Levorphanol PO 2 mg [2 to 4 mg] q 6 to 8 h 

(Max. initial dose: 6 to 12 mg/d) 

30-60 

60 to 120 

4 to 8 


11 to 16 

• Elderly – consider reducing dose by ≥ 50% or 

more. 

• Hepatic / Renal dysfunction – No 

pharmacokinetic data; use with caution. 

• Respiratory disease / respiratory depressants – 

Reduce initial dose by ≥ 50%. 

IM 

1 mg [1 to 2 mg] q 6 to 8 h 


15 to 30 

— 

— 

• Duration of analgesic effect is longer than that 

of morphine or meperidine. When making 

dosage adjustments, allow sufficient time 

(72 h) to permit a new steady-state before 

making subsequent dosage changes to avoid 

excessive drug accumulation. 

IV 

≤ 1 mg (0.02 mg/kg) q 3 to 6 h 

(slowly) 


10 to 15 





ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Morphine (cont.) IM 10 mg q 3 to 4 h 

1 to 5 

[2.5 to 20 mg q 4 h] 

30 to 60 

2 to 7 

IV 3 to 5 mg [2 to 15 mg] q 2 to 3 h; 

(dilute in 4 to 5 ml of sterile water 

for injection and inject slowly 

over 4 to 5 min); 





ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

15 to 60 

30 

6 to 24 § 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



ED § Single dose 2 to 5 mg 

(0.04 to 0.10 mg/kg) [2 to 

7.5 mg]; if pain relief is 

inadequate after 1 h, incremental 

doses of 1 to 2 mg may be given 

at intervals long enough to assess 

effectiveness; max. 10 mg/24 h 

Infusion 0.08 to 0.17 mg/h (2 to 

4 mg/24 h) [0.1 to 1 mg/h]; 

additional 1 to 2 mg may be given 

if pain relief is not obtained 

initially. 

PCEA Load 2 to 4 mg; basal 

infusion || 0.3 to 0.6 mg/h; demand 

dose 0.1 to 0.2 mg; lockout 

interval 10 to 15 min. ‡‡ (Usual 

initial dose, 4 to 10 mg/d; often 

titrated up to 20 to 30 mg/d). 

Morphine (cont.) IT § 0.2 to 1 mg/d 

[0.2 to 1 mg/d]; (0.004 to 0.02 

mg/kg/d); repeated doses not 

recommended. 

IV PCA Load 0.5 to 3 mg (0.01 to 0.06 

mg/kg); bolus/demand dose 0.5 to 

3 mg; lockout 6 to 8 min; basal 

infusion || 0.5 to 2 mg/h 

15 to 60 

30 

6 to 24 § 

— 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Oxycodone PO IR: 

5 mg q 6 h [5 to 15 mg q 4 to 6 h] 

CR: 

10 mg [10 to 80 mg] q 12 h 

10 to 15 

30 to 60 

3 to 6 

30 to 60 

90 to 180 

8 to 12 


Metabolized to oxymorphone via 

CYP-2D6 isoenzyme. 

3.2 

— 

— 

4.5 

• Elderly and debilitated patients – reduce 

dosage. 

• Hepatic / Renal – Use with caution. 

• Patients on other CNS depressants: reduce 

dosage. 

• Metabolized to oxymorphone. May be 

ineffective in patients with decreased CYP- 

2D6 activity (due to poor CYP-2D6 

metabolism or CYP-2D6 inhibiting drugs). 

• Parenteral and IR oral opioids are generally 

preferred over CR/SR oral opioids for 

management of post-operataive pain. 

Oxymorphone IM 0.5 to 1.5 mg q 4 to 6 h 10 to 15 

30 to 60 

3 to 6 

IV 0.5 mg q 4 to 6 h 

5 to 10 

[0.5 to 1 mg q 2 to 6 h] 

30 to 60 

3 to 6 


1.3 ± 0.7 (mean ± SD) 

• Elderly and debilitated – reduce dosage. 

• Hepatic dysfunction – reduce dosage. 

• Renal dysfunction – use with caution. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Oxymorphone (cont.) SC 0.5 to 1.5 mg q 4 to 6 h 10 to 15 

— 

3 to 6 

PR 5 mg q 4 to 6 h 

15 to 30 

[5 to 10 mg q 3 to 6 h] 

— 

3 to 6 

Phenylpiperidines 

Alfentanil ED § Single dose 500 to 1000 µg (10 to 15 


• Elderly – 50% reduction in dose typically. 

20 µg/kg) 

— 

Metabolized by CYP-3A3/4 • Hepatic dysfunction – in patients with 

Infusion 100 to 250 µg/h (2 to 5 1 to 3 § 1 to 2 †† moderate hepatic insufficiency, protein 

µg/kg/hr) 

binding is decreased (free, active drug is 

PCEA No recommendation for 

increased), clearance is decreased about 50%, 

basal infusion || ; demand dose 200 

and half-life is increased; use with caution as 

to 250 µg; lockout interval 

effects may be increased and prolonged. In 

10 min. ‡‡ patients with severe hepatic insufficiency, 

reduce dose. 

• Renal dysfunction – no dosage modification. 

• Obesity (> 20% above IBW) – base dose on 

IBW. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Fentanyl 

IM 

[25 to 100 µg (0.7 to 2 µg/kg)] 

prn 

< 7 to 15 





ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

— 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Fentanyl (cont.) IV PCA Load 15 to 75 µg (0.5 to 

1 µg/kg); bolus/demand dose 10 

to 75 µg; lockout 4 to 6 min; 

basal infusion || 15 to 60 µg/h 

Meperidine 

PO 100 to 150 mg q 3 h 

[50 to 150 mg (1 to 3 mg/kg) q 2 

to 4 h] 

10 to 45 

< 60 

2 to 4 


Metabolized to neurotoxic 

metabolite, normeperidine, which is 

renally eliminated. 

PO 3 to 4, meperidine; 

IM 8 to 21, normeperidine 

• Suggested max. dose 600 mg / 24 h, and max. 

duration 24 h. 

• Has local anesthetic properties. 

• May be useful for prevention and treatment of 

postoperative shivering. 

• Elderly – consider age-dependent renal 

impairment; reduce dosage or avoid use. 

• Hepatic dysfunction – decrease dose, 

frequency of administration, and avoid regular 

use; bioavailability is increased and half-life (7 

to 11 h) prolonged in patients with cirrhosis or 

active viral hepatitis. Normeperidine may 

accumulate, although less is formed. 

• Renal dysfunction – not recommended because 

of accumulation of neurotoxic metabolite; 

elimination half-life of normeperidine in renal 

failure is increased (35 h). 

• Concomitant therapy with other CNS 

depressants (e.g., phenothiazines, other 

tranquilizers) – reduce dose of meperidine 

25% to 50%. 

• Seizures may occur with regular or high doses 

and with renal failure. Alkaline urine reduces 

elimination of meperidine and normeperidine. 

• SC meperidine causes local irritation and is 

not recommended when repeated injections are 

required. 

IM 

75 to 100 mg q 3 h 

[50 to 150 mg q 2 to 4 h] 

1 to 5 

30 to 50 

2 to 4 






Meperidine (cont.) 

ROUTE 

IV 




(18 TO 65 Y) 

Intermittent dosing 25 to 50 mg 

q 2 h (slowly at ≤ 25 mg/min) 

[25 to 100 mg (0.5 to 2 mg/kg) 

q 2 to 4 h] 

Slow, continuous infusion 

[15 to 35 mg/h] 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

< 1 

5 to 20 

2 to 4 

SC same as PO — 

— 

2 to 4 

ED § Single dose 20 to 100 mg (0.5 to 

2 mg/kg) 

Infusion [2 to 20 mg/h] 

PCEA Load 30 mg; no basal 

infusion; demand dose 30 mg; 

lockout 30 min. ‡‡ 2 to 12 

— 

4 to 8 § 

IV PCA Load 25 to 50 mg (0.5 to 1 — 

mg/kg); bolus/demand dose 5 to 

25 mg; lockout 6 to 8 min; basal 

infusion || 5 to 20 mg/h. 

Remifentanil IV Continuation of analgesia into 1 

immediate postoperative period: 1 

continuous infusion 

0.1 µg/kg/min (range: 0.025 to 

5 to 10 min 

0.2 µg/kg/min); supplemental 

bolus not recommended. 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 

Nonspecific plasma and tissue 

esterases 

IV ~3 to 10 min †† 



• Note: Before stopping the infusion of 

remifentanil, consider the short offset of the 

drug (5 to 10 min); give alternate analgesic 

before stopping remifentanil. 

• Should be used only under immediate 

direction and supervision of anesthesia care 

provider. 

• Elderly (> 65 y) – Decrease starting doses by 

50%; cautiously titrate to effect. 

• Hepatic / Renal dysfunction – No dosage 

modification required. 

• Obesity (> 30% over IBW) – Base initial dose 

on IBW. 






Sufentanil 

ROUTE 

IV 

ED § 




(18 TO 65 Y) 

For minor general surgery 

(duration ≤ 2 h): total dose 1 to 

2 µg/kg; maintenance: 10 to 

25 µg in increments as needed for 

surgical stress or lightening of 

anesthesia. Adjust maintenance 

infusion rates based on the 

induction dose so that the total 

dose is < 1 µg/kg/h of expected 

surgical time. 

For major surgery (duration 2 to 

8 hr): total dose 2 to 8 µg/kg; 

maintenance: 10 to 50 µg. Adjust 

maintenance infusion rates based 

on the induction dose so that the 

total dose is < 1 µg/kg/h of 

expected surgical time. 

Single dose: 4 to 75 µg, or 10 to 

15 µg with 10 ml bupivacaine 

0.125% (12.5 mg, with or without 

epinephrine); may repeat twice at 

≥ 1 h intervals (total, 3 doses) 

Infusion 4 to 8 µg/h. 

PCEA Load 30 to 50 µg; basal 

infusion || 5 to 10 µg/h; demand 

dose 4 to 6 µg; lockout interval 

6 min. ‡‡ 5 

IV PCA Load 2 to 10 µg (0.03 to 0.1 

µg/kg); bolus/demand dose 2 to 

10 µg; lockout 4 to 6 min; basal 

infusion || 2 to 8 µg/h 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

— 

2.5 

1 to 2 after 1 to 

2 µg/kg IV 

2 to 8 h after 2 

to 8 µg/kg IV 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 

Hepatic / Renal, fecal 

IV 2.5 †† 

. 

— 

2 to 4 § 

— 



• Elderly and debilitated – reduce dosage. 

• Hepatic / renal dysfunction – No change in 

pharmacokinetics; use with caution in patients 

with chronic renal failure due to possible 

prolonged respiratory depression. 

• Obesity (> 20% above IBW) – base dose on 

IBW. 

• For IV injection, individualize supplemental 

dosages. 

• Sufentanil and bupivacaine may be mixed 

together before ED administration. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Diphenylheptanes 

Methadone 

PO 

5 to 10 mg q 4 to 6 h for first 2 to 

3 d; with repeated dosing, extend 

interval to q 6 to 12 h 

[2.5 to 10 mg q 4 to 6 h for first 2 

to 3 d, then 5 to 20 mg q 6 to 12 h 

(0.05 to 0.1 mg/kg)] 

30 to 60 

— 

4 to 12; 

increases with 

continued use 

and cumulative 

effects 

Hepatic / Renal, fecal 

Primarily metabolized by CYP-3A4 

13 to 47 (mean, 25, with repeated 

PO doses) 

• Elderly, poor-risk, or debilitated patients – 

reduce dosage. 

• Hepatic dysfunction – In severe hepatic 

dysfunction, half-life is increased and 

accumulation may occur. In mild to moderate 

hepatic dysfunction, no dosage modification 

required. 

• Renal dysfunction – reduce dose by up to 

50% in end-stage renal failure or dialysis 

patients. 

• Patients on other CNS depressants – reduce 

dosage. 

• Undergoes renal reabsorption, which 

decreases as urinary pH decreases. Urinary 

excretion is dose-dependent and is the major 

route of elimination at doses > 55 mg/d. 

• SC injection may cause local irritation. 

• Oral route usually not used for postoperative 

pain. 

IM 

2.5 to 5 mg q 4 h; with repeated 

dosing, extend interval to q 6 h 

[2.5 to 10 mg q 3 to 4 h then 5 to 

20 mg q 6 to 8 h (0.05 to 0.1 

mg/kg)] 

1 to 5 

30 to 60 

4 to 6 (single 

dose) 

IV 

Not FDA-approved. 





ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

Methadone (cont.) SC same as IM 1 to 5 

— 

4 to 6 (single 

dose) 

ED § Single dose 1 to 5 mg (0.02 to 

0.1 mg/kg) 

Infusion 0.3 to 0.5 mg/h 

5 to 10 

— 

6 to 10 § 

Propoxyphene PO HCl 65 mg q 6 to 8 h [65 to 

130 mg q 8 h]; max. 390 mg/d 

Napsylate 100 mg q 6 to 8 h 

[100 to 200 mg q 8 h]; max. 

600 mg/d 

Equianalgesic doses for 

propoxyphene salts: 65 mg HCl ≡ 

100 mg napsylate. 

15 to 60 

120 to 180 

4 to 6 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 


6 to 12 

(30 to 36, norpropoxyphene) 

Metabolized to norpropoxyphene 

(associated with cardiotoxicity). 



• Elderly – Use is not recommended (Beers 

1997); half-life of propoxyphene and 

norpropoxyphene may be markedly 

prolonged (36 and 53 h, respectively) (Crome 

et al. 1984). 

• Hepatic disease – Increased bioavailability of 

propoxyphene; reports of hepatotoxicity; 

avoid use in patients with liver disease. 

• Renal dysfunction – Propoxyphene and 

norpropoxyphene accumulate in renal 

insufficiency; may result in respiratory or 

CNS depression, neurotoxicity, or 

cardiotoxicity; avoid use. 

• Seizures and cardiac arrhythmias may occur 

with the use of high doses or with renal 

failure. 






ROUTE 




(18 TO 65 Y) 

MIXED AGONIST-ANTAGONIST OPIOIDS 

Buprenorphine 

IM 0.3 to 0.6 mg q 6 to 8 h (0.006 to 

0.012 mg/kg); repeat once (up to 

0.3 mg) in 30 to 60 min prn 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

IV same as IM (give slowly) < 15 

< 60 

6 

Butorphanol IM 2 mg [1 to 4 mg (0.02 to 0.08 

mg/kg)] q 3 to 4 h 

Preoperative / Preanesthetic use: 

2 mg 60 to 90 min before surgery. 

10 to 15 

30 to 60 

3 to 4 

IV 1 mg [0.5 to 2 mg (0.01 to 0.04 

mg/kg)] q 3 to 4 

15 

60 

6 

< 3 

< 30 

3 to 4 

Hepatic / Fecal 

2 to 3 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 

Hepatic / Renal, Fecal 

IV 2.1 to 8.8 



• Elderly, debilitated – reduce dose by 50%. 

• Hepatic dysfunction – insufficient data. 

• Renal dysfunction – no dosage modification 

required. 

• Respiratory disease; presence of other CNS 

depressants – reduce dose by 50%. 

• Relative antagonist activity: equipotent to 

that of naloxone. 

• Do not use in patients who have physiologic 

opioid dependence as it may precipitate 

withdrawal. 

• Elderly (≥ 65 y) – IM/IV: reduce dose by ½ 

and double the dosing interval. 

• Hepatic / Renal dysfunction (CrCl 

< 30 ml/min) – extend dosing frequency to 

q 6 to 8 h. 

• Relative antagonist acitvity: ~30x 

pentazocine or 1/40 naloxone. 

• Ceiling effect on respiratory depression 

occurs at ~30 to 60 µg/kg. 



withdrawal. 






ROUTE 




(18 TO 65 Y) 

Dezocine IM 10 mg [5 to 20 mg]; repeat q 3 to 

6 h prn 

Max. ~120 mg/d 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

< 30 

30 to 150 

3 to 4 (after 10 

to 15 mg IM) 

IV 5 mg [2.5 to 10 mg] q 2 to 4 h < 15 

— 

2 (after 5 mg 

IV) 

SC Not recommended because of — 

injection site reactions (4% in 

clinical trials) 

Nalbuphine IM 10 mg [10 to 20 mg (0.1 to 0.3 

mg/kg)] q 3 to 6 h prn 

Max. 160 mg/d 

< 15 

60 

3 to 6 


IV 0.6 to 7.4 


5 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



• Elderly – reduce initial dose and 

individualize subsequent doses. 

• Hepatic / Renal dysfunction – reduce dose. 

Half-life is increased by 30% to 50% in 

patients with cirrhosis compared with healthy 

volunteers after 10 mg IV. 

• Exhibits nonlinear (dose-dependent) 

pharmacokinetics at doses > 10 mg with 

serum concentration-time curve ~25% 

greater, and total body clearance ~20% lower 

compared with doses ≤ 10 mg. 

• Relative antagonist acitvity less than that of 

nalorphine and greater than that of 

pentazocine. 



withdrawal. 

• Elderly – insufficient data; use with caution 

• Hepatic / Renal dysfunction – reduce dose 

• Relative antagonist activity: 10x that of 

pentazocine 

• Ceiling to respiratory depressant effects seen 

at doses ~30 mg 



withdrawal. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

Nalbupine (cont.) IV same as IM 2 to 3 

30 

— 

SC same as IM < 15 

ND 

— 

Pentazocine PO 25 to 50 mg [25 to 100 mg] every < 15 to 30 

4 to 8 h 

< 60 to 180 

Max. 600 mg/d 

3 


2.2 to 3.6 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 

. 



• Elderly (60 to 90 y) – Clearance is decreased 

and half-life increased (Ritschel, 1986) 

consider dosage modification. 

• Hepatic dysfunction – Oral bioavailability is 

increased 2- to 3-fold, clearance decreased 

about 50%, and half-life doubled in patients 

with cirrhosis. Use lower dosage and extend 

dosing interval, or use alternative analgesic. 

• Renal dysfunction – insufficient data. 

• Weak antagonist activity. 

• Wide interindividual variability in rate of 

metabolism may explain variable and 

unpredictable analgesic response after oral 

administration. 

• SC injections may result in severe tissue 

damage and should be used only when 

necessary. 



withdrawal. 






ROUTE 




(18 TO 65 Y) 

ANALGESIC 

ONSET 

(MIN) 

PEAK (MIN) 

DURATION 

(H) 

< 15 to 20 

< 15 to 60 

3 

< 12 to 30 

ND 

3 

ND 

ND 

3 

METABOLISM / 

ELIMINATION 

HALF-LIFE (H) 



Pentazocine (cont.) IM 20 to 30 mg [20 to 60 mg (0.5 to 

1 mg/kg)]; may repeat q 2 to 4 h 

(max. 60 mg/dose, 360 mg/d) 

IV 

30 mg (0.3 to 0.5 mg/kg); may 

repeat q 2 to 4 h (max. 

30 mg/dose, 360 mg/d) 

SC 

20 to 30 mg [20 to 60 mg]; may 

repeat q 2 to 4 h (max. 

60 mg/dose, 360 mg/d) 

OTHER 

Tramadol PO 50 to 100 mg q 4 to 6 h (max. 

400 mg/d) 

< 60 

~120 to 240 

3 to 6 


Hepatically metabolized to active 

M1 metabolite. (In animal studies, 

M1 had 6 times the analgesic 

potency and 200 times the µ-opiate 

binding potency of tramadol.) 

6 to 7 

(for tramadol and M1 metabolite) 

• Elderly– 65 to 75 y: no dosage adjustment 

except with renal or hepatic impairment; 

>75 y: give < 300 mg/d in divided doses. 

• Hepatic dysfunction – decrease dosage to 

50 mg q 12 h in patients with cirrhosis. 

• Renal dysfunction (CrCl < 30 ml/min) – 

increase dosing interval to 12 h and decrease 

maximum daily dose to 200 mg. Dialysis 

patients can receive their regular dose on the 

day of dialysis (< 7% of a dose is removed by 

hemodialysis). 



withdrawal. 

Sources (AHFS, 2000; Anonymous, 2001a; Anonymous, 2001b; Austrup & Korean, 1999; Davies et al., 1996; Donnelly & Shafer, 1995; DuPen et al., 2000; Koo, 1995; Kruger & McRae, 

1999; MCCaffery & Pasero 1999; Miyoshi & Leckband, 2000; Omoigui, 1995; Picard et al., 1997; Rawal, 1999; Ready, 2000; Scholz et al. , 1996; Stevens & Edwards, 1999; Tegeder et 

al.,1999). 

CNS = Central nervous system; CR=Controlled release; CrCl = Creatinine clearance; ED = Epidural; GI = Gastrointestinal; IBW = Ideal body weight; IM = Intramuscular; IT = 

Intrathecal; IV = Intravenous; ND = No data; PCEA = Patient-controlled epidural analgesia; PCIA = Patient-controlled intravenous analgesia;; PO = Per os (oral); PR = Per rectum; prn = 

pro re nata (as needed); SC = Subcutaneous; SD = Standard deviation; SR = Sustained release,. 





† 

|| 

§ 

†† 

‡‡ 

Agents shown in bold are listed on the VA National Formulary (VANF, as of Dec. 2001); agents shown in italic are listed on the DoD Basic Core Formulary (BCF, as of 15 Nov. 

2001); agents shown in bold italic are listed on both the VANF and BCF. Check listings for specific formulations and restrictions. 

Basal infusion for IV PCA is optional. Some evidence exists that a basal infusion offers no advantages and may increase adverse effects; routine use of basal infusions are not 

recommended for acute pain management by some authors (Parker RK, Holtzman B, et al., 1992; Parker RK, Sawaki Y, et al., 1992). 

Central neuraxial (epidural or intrathecal) drugs should be preservative-free and diluted with sterile normal saline. Doses refer to injections of the lumbar region; low doses may be 

effective when injected in the cervical or thoracic region. The epidural space can safely tolerate up to about 20 ml/h of fluid. ED and IT doses and duration of analgesia vary widely 

between individuals; doses shown are only guidelines. Epidural doses are usually about 1/10 of intravenous doses, and intrathecal doses are about 1/10 to 1/5 of epidural doses. 

Elderly patients may require very small doses of ED morphine. The dose of ED morphine required after abdominal hysterectomy has been found to be inversely related to patient age 

according to the equation: 

Effective 24-h epidural morphine dose (mg) = 18 – age (0.15) (Ready et al., 1987). 

Because the pharmacokinetics of alfentanil, fentanyl, sufentanil, and remifentanil are multi-compartmental, the context-sensitive half-time (CSHT) is a more useful parameter than 

elimination half-life to describe the time for blood drug concentrations to decrease by 50% after variable-length infusions (Hughes et al., 1992; Shafer & Varvel, 1991). For 

alfentanil, fentanyl, and sufentanil, the CSHT may increase the longer the infusion. For example, based on computer simulations, the CSHT for 100- and 200-min infusions are, 

respectively, about 45 and 55 min for alfentanil, 50 and > 100 min for fentanyl, and 20 and 25 min for sufentanil. The CSHT for remifentanil is unique in that it is consistently short 

(< 5 min) and analgesic effects dissipate rapidly independent of the infusion duration (Egan et al., 1993: Kapila et al., 1995). 

PCEA doses are for use with lumbar epidural catheters. Consider reducing dosage for use with thoracic catheters. 




Table OP2.5. Opioids: Dosage Formulations 

OPIOID † ROUTE FORMULATIONS 

PURE AGONISTS 

Phenanthrenes 

Codeine PO Tablets/Capsules (doses in mg): 

Codeine alone 15, 30, 60 

Codeine/APAP 15/300, 30/300, 60/300 

Codeine/ASA 30/325, 60/325 

Liquids: 

Codeine alone 15 mg/5 ml 

Codeine/APAP 12/120 mg/5 ml 

IM 

IV Injection: 30 and 60 mg/ml 

SC 

Hydrocodone PO Tablets/Capsules (doses in mg): 

Hydrocodone/APAP 2.5/500, 5/500, 7.5/650, 7.5/750, 10/325, 10/500, 10/650 

Hydrocodone/ASA 5/500 

Hydrocodone/Ibuprofen 7.5/200 

Liquid: 

Hydrocodone/APAP 2.5/167 mg/5 ml (7.5/500 mg/15 ml) 

Hydromorphone PO Tablets: 1, 2, 3, 4 and 8 mg 

Liquids: 5 mg/5 ml 

IM 

IV 

SC 

IV PCA 

PR 

ED 

IT 

Injection: 1, 2, 4, and 10 mg/ml 

Suppositories: 3 mg 

Check label for preservative-free formulation for injection. 







Levorphanol PO Tablets: 2 mg 

Morphine 

IM 

IV 

SC 

PO 

Injection: 2 mg/ml 

IR tablets: 15, 30 mg 

CR/SR tablets: 15, 30, 60, 100, 200 mg 

Liquids: 10 mg/5 ml, 20 mg/5 ml, 20 mg/1 ml 

Injection: 0.5, 1, 2, 4, 5, 8, 10, 15, 25, 50 mg/ml 

IM 

IV 

SC 

PCA syringes: 1 and 5 mg/ml, 30 ml 

IV PCA 

PR Rectal suppositories: 5, 10, 20, 30 mg 

ED Preservative-free injection: 

IT 0.5, 1, 10, 15, 25, and 50 mg/ml 

Oxycodone PO IR tablets/capsules (doses in mg): 

Oxycodone alone 5, 15, 30 

Oxycodone/APAP: 2.5/325, 5/325, 5/500, 7.5/500, 10/650 

Oxycodone/ASA: 2.25/325, 4.5/325 

CR tablets: 10, 20, 40 and 80 mg 

Liquids: 

Oxycodone alone 5 mg/5 ml, 20 mg/1 ml 

Oxycodone/APAP 5/325 mg per 5 ml 

Oxymorphone 

IM Injection: 1 and 1.5 mg/ml 

IV 

SC 

PR Suppositories: 5 mg 


Alfentanil ED Preservative-free Injection: 500 mcg/ml 






Fentanyl 

IM 

IV 

IV PCA 

Injection: 50 mcg/ml 

ED Check label for preservative-free formulation for injection. 

IT 

Meperidine 

PO Tablets: 50, 100 mg 

Liquid: 50 mg/5 ml 

IM 

IV 

SC 

IV PCA 

Injection: 10, 25, 50, 75 & 100 mg/ml 


Remifentanil IV Preservative-free injection: 1 mg/ml 

Sufentanil 

IV Injection: 50 mcg/ml 

IV PCA 

ED Preservative-free injection: 50 mcg/ml 


Methadone 

PO Tablets: 5 & 10mg 

Liquids: 5 mg/5ml, 10 mg/5ml, 10 mg/1ml 

IM 

IV 

SC 

Injection: 10 mg/ml 


Propoxyphene PO Tablets/capsules (doses in mg): 

Propoxyphene 65, 100 

Propoxyphene HCl/APAP 65/650 

Propoxyphene Napsylate/APAP 50/325, 100/650 

Propoxyphene HCl/ASA/Caffeine 65/389/32.4 






MIXED AGONIST-ANTAGONISTS OPIOIDS 

Buprenorphine 

IM 

IV 

Injection: 0.324 mg (equivalent to 0.3 mg buprenorphine) / ml 

Butorphanol 

IM 

IV 

Injection: 1 and 2 mg/ml 

Dezocine 

IM 

IV 

SC 

Injection: 5, 10, and 15 mg/ml 

Nalbuphine 

IM 

IV 

SC 

Injection: 10 and 20 mg/ml 






Pentazocine 

PO Tablets (doses in mg): 

Pentazocine/APAP 25/650 

Pentazocine/ASA 12.5/325 

Pentazocine/Naloxone 50/0.5 

IM Injection: 30 mg/ml 

IV 

SC 

OTHER 

Tramadol PO Tablets: 50 mg 

† 






Table OP3. Opioids: Drug Interactions 

PRECIPITANT DRUG OBJECT DRUG 

EFFECT OF 

OBJECT DRUG 

DESCRIPTION 

Agonist-antagonist opioids Pure agonist opioids ↓ Opioid-dependent patients may develop withdrawal symptoms. 

Barbiturate anesthetics, 

other CNS depressants 

Chlorpromazine 

Thioridazine 

MAOIs: 

• Phenelzine 

• Tranylcypromine 

• Isocarboxazid 

• Selegiline 

Cimetidine 

Carbamazepine 

Phenobarbital 

Phenytoin 

Primidone 

Protease inhibitors: 

• Indinavir 

• Nelfinavir 

• Ritonavir 

• Saquinavir 

Rifampin 

Pure agonist and mixed 

↑ Additive pharmacologic effects may increase the respiratory and CNS depression of the opioid. 

agonist-antagonist opioids 

Pure agonist opioids ↑ Potentiate analgesic effects, but also toxic effects. Avoid combination with meperidine. 

Pure agonist opioids 

Tramadol 

Alfentanil 

Fentanyl 

Meperidine 

Methadone 

Meperidine 

Methadone 

Alfentanil 

Fentanyl 

Hydrocodone 

Meperidine 

Methadone 

Oxycodone 

Propoxyphene 

Hydrocodone 

Oxycodone 

Methadone 

Morphine 

Alfentanil 

Fentanyl 

↑ 

↑ 

↓ / ↑ 

↑ 

↓ 

Unpredictable, potentially fatal serotonin-like syndrome due to combination of meperidine and 

nonselective MAOIs; interaction is possible with the selective MAOI, selegiline. Reaction may occur 

2 to 3 weeks, possibly > 3 weeks, after discontinuation of MAOIs. Morphine use with MAOIs doesn’t 

seem to result in such severe reactions; however, MAOIs markedly potentiate the effects of morphine. 

Possible increased central nervous system or respiratory depression due to decreased metabolism 

(CYP-3A4) and clearance. Alternatives to cimetidine with less potential to interact: famotidine, 

nizatidine, ranitidine. Cimetidine may also inhibit opioid-induced histamine release. 

Possible decreased pharmacologic effects of meperidine or methadone, or opioid withdrawal due to 

increase in hepatic metabolism of the opioids. Increase in normeperidine formation occurs with 

phenobarbital and phenytoin, and is also possible with carbamazepine and primidone. Combination of 

antiepileptic and analgesic agents has additive CNS depressant effects. 

Marked increase in bioavailability, especially with fentanyl, meperidine, and propoxyphene. Avoid 

combination with meperidine and propoxyphene. Monitor for increased central nervous system and 

respiratory depression with the other opioids. 

Rifampin-induced increase in hepatic metabolism may decrease opioid blood concentrations, resulting 

in withdrawal symptoms or loss of analgesic effect. 

Propoxyphene Warfarin ↑ Propoxyphene in combination with acetaminophen has been reported to enhance 

hypoprothrombinemic effects of warfarin. Effect of propoxyphene alone on oral anticoagulant effects 

has not been documented. 




Table OP3. Opioids: Drug Interactions 

PRECIPITANT DRUG OBJECT DRUG 

EFFECT OF 

OBJECT DRUG 

DESCRIPTION 

Propoxyphene Carbamazepine ↑ May increase carbamazepine concentrations and result in clinical signs of toxicity. 

Quinidine, SSRIs 

(paroxetine, fluoxetine, 

sertraline), and other CYP- 

2D6 inhibitors 

Erythromycin 

Clarithromycin 

Troleandomycin 

SSRIs: 

• Citalopram 

• Sertraline 

• Fluoxetine 

• Fluvoxamine 

• Paroxetine 

Diltiazem 

Verapamil 

Codeine 

Dihydrocodeine 

Hydrocodone 

Oxycodone 

Tramadol 

↓ 

Avoid combination; decreased or loss of analgesic effects due to inhibition of metabolism of codeine 

to morphine (may decrease morphine concentration by 95%); interaction expected to affect extensive 

metabolizers. Similar interaction may decrease conversion of hydrocodone to hydromorphone, and 

oxycodone to oxymorphone. Tramadol metabolism is partially dependent on CYP-2D6 and is 

expected to be less affected than codeine. 

Alfentanil ↑ Marked increase in bioavailability of alfentanil; possible prolonged anesthesia or increased respiratory 

depression. Clarithromycin and troleandomycin are also likely to interact. Alternatives to 

erythromycin with less potential to interact: azithromycin and dirithromycin. 

Tramadol 

Meperidine 

Alfentanil 

Fentanyl 

Sufentanil 

↑ 

↑ 

Serotonin-like syndrome reported with combination of tramadol and sertraline or paroxetine. 

Interaction is possible with other SSRIs and with meperidine. Consider non-serotonergic analgesics. 

Use combination with caution; monitor for signs and symptoms of excessive serotonergic effects. 

Diltiazem appears to inhibit CYP-3A4 metabolism of alfentanil. Interaction has resulted in prolonged 

half-life of alfentanil and delayed extubation. Fentanyl and sufentanil are likely to be affected. 

Verapamil may also inhibit metabolism of alfentanil. 

Alcohol Propoxyphene ↑ Acute alcohol ingestion may increase propoxyphene bioavailability. Ingestion of large quantities of 

alcohol with propoxyphene has been associated with fatalities. Mechanism is unclear, but appears to 

be due to additive or synergistic CNS and respiratory depressant effects. 

Sources / Adapted from: (Anonymous, 2001; Fromm et al., 1997; Hansten et al., 2000; Michalets, 1998). 

CNS = Central nervous system; MAOI = Monoamine oxidase inhibitor; SSRI = Selective serotonin reuptake inhibitor 

↑ = Effect of object drug increased ↓ = Effect of object drug decreased 




Table OP4. Opioids: Equianalgesic Dosing 

EQUIANALGESIC DOSE (mg) BY ROUTE ‡ 

OPIOID AGENT † PO IM IV SC PR TM 

PURE AGONISTS 

Phenanthrenes 

Codeine 180 to 200 ‡‡ 120 to 130 120 120 

Hydrocodone 30 

Hydromorphone 7.5 1 to 2 1.3 to 1.5 1 to 1.5 6 

Levorphanol 4 2 2 2 

Morphine 30 to 60 10 10 10 22.5 

Oxycodone 20 to 30 ‡‡ 

Oxymorphone 1 to 1.5 1 1 to 1.5 5 to 10 


Fentanyl 0.1 to 0.2 ND 0.4 to 0.8 

Meperidine 300 ‡‡ 75 to 100 ND 75 to 100 


Methadone 10 to 20 †† 10 †† 10 †† 8 to 10 †† 

Propoxyphene 100 to 130 

MIXED AGONIST-ANTAGONIST OPIOIDS 

Buprenorphine 0.3 0.3 

Butorphanol 2 to 3 2 

Dezocine 10 10 

Nalbuphine 10 10 10 

Pentazocine 150 30 30 30 

OTHER 

Tramadol ~100 to 150 

Sources: Drug Facts and Comparisons, 2001; AHFS Drug Information, 2000; PDR, 2001; Du Pen et al., 2000; Koo, 1995, American Pain Society 1999. 

A blank cell means the drug is not available in the U.S. by the respective route of administration and therefore an equianalgesic dose is not applicable. 

ED = Epidural; IM = Intramuscular; IT = Intrathecal; IV = Intravenous; ND = No data; PO = Per os (oral); PR = Per rectum; SC = Subcutaneous; TM = Transmucosal 

† 



‡ 

Equivalent doses based on morphine 10 mg IM or SC. The initial dose of the new drug applies to patients who are not tolerant to opioids and should be given at 50% to 67% of the 

calculated dose (except use 10% to 25% for methadone; see footnote below) to allow for incomplete cross-tolerance (the new drug may have more relative analgesic efficacy and 

more adverse effects). Doses of mixed agonist-antagonist opioids and tramadol should NOT be considered equianalgesic to the doses of pure agonists. 




Table OP4. Opioids: Equianalgesic Dosing 

†† 

The initial dose of methadone should be given at 10% to 25% of the calculated dose; dosing of methadone is controversial. 

‡‡ 

Starting doses lower (codeine, 30 mg; oxycodone, 5 mg; meperidine, 50 mg). Codeine exhibits a ceiling effect at doses > 60 mg.(Walker and Zacny, 1998). 


Version 1.2 



Opioids 

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ACETAMINOPHEN AND NSAIDs 

Acetaminophen and the NSAIDs are among the most commonly used analgesic medications. Their 

efficacy has been established in certain types of postoperative pain (cf. Cochrane reviews, acetaminophen 

with and without codeine, ibuprofen and diclofenac). They are most effective in the treatment of mild to 

moderate pain and are also effective as adjunctive or opioid-sparing agents in the treatment of moderate to 

severe pain (NHMRC, 1999). Although these medications are widely used and have documented efficacy 

for postoperative pain, they are associated with adverse effects that should be considered when selecting 

analgesic therapy. 

Key points 

• Acetaminophen and the NSAIDs (including COX-2–selective inhibitors) act by mediating pyretic 

and pain pathways. NSAIDs (including COX-2–selective inhibitors) also have anti-inflammatory 

properties. 

• These agents are generally safe and well tolerated. However, excessive doses of acetaminophen 

have been associated with hepatotoxicity. NSAIDS (including COX-2–selective inhibitors) can 

cause significant alteration in renal, bronchial, and gastric mucosa function. 

• NSAIDs (including COX-2–selective inhibitors) should be avoided in patients who have 

- hypersensitivity to NSAIDs, particularly in patients who have developed NSAID- or aspirininduced 

asthma, rhinitis, nasal polyps, or other symptoms of allergic or anaphylactoid 

reactions; 

- hypersensitivity to sulfonamides (avoid celecoxib); 

- peptic ulcer disease; or 

- significant renal impairment. 

• NSAIDS (including COX-2–selective inhibitors) should be used with caution in patients who 

- are elderly (age > 65 years); 

- have hypertension; 

- have renal impairment; or 

- have congestive heart failure. 

• Adverse reactions occurring with NSAIDs (including COX-2–selective inhibitors) include the 

following: 

- anaphylaxis 

- GI bleeding 

- intraoperative bleeding 

- acute renal failure 

- bronchospasm 

- thrombocytopenia 

- Stevens-Johnson syndrome 

- nephritis 

- hepatotoxicity 

- agranulocytosis 

Pharmacologic Management: NSAIDs Page 49

Version 1.2 



• Common reactions experienced by patients taking NSAIDs (including COX-2–selective 

inhibitors) include the following: 

- stomach upset 

- nausea 

- abdominal pain 

- constipation 

- diarrhea 

- headache 

- dizziness 

- rash 

- urticaria 

- drowsiness 

- fluid retention 

- tinnitus 

• Decisions regarding the use of acetaminophen or an NSAID for postoperative analgesia should be 

guided by the patient’s characteristics and the desired balance between analgesic efficacy and 

adverse effect. 




Summary Table. Site-specific Indications—Acetaminophen & NSAIDs 




Ophthalmic NS NS NS -- -- RARELY C X If there is risk of or actual bleeding, avoid NS* 

Craniotomy NS NS NS -- -- If there is risk of or actual bleeding, avoid NS* 


Radical neck NS NS NS -- -- X 

Oral-maxillofacial NS NS NS -- -- C, I X 


Thoracotomy NS NS NS C, T X If there is risk of or actual bleeding, avoid NS* 


Mastectomy NS NS NS C, T X 

Thoracoscopy NS NS NS C, T X 


CABG NS NS NS RARELY RARELY If there is risk of or actual bleeding, avoid NS* 


MID-CAB NS NS NS RARELY X If there is risk of or actual bleeding, avoid NS* 


4. Upper abdomen 

Laparotomy NS NS NS E, T X If there is risk of or actual bleeding, avoid NS* 


Laparoscopic cholecystectomy NS NS NS RARELY RARELY E, T X 

Nephrectomy NS NS NS E, T X 


Hysterectomy NS NS NS E, X 

Radical prostatectomy NS NS NS -- E X If there is risk of or actual bleeding, avoid NS* 


Hernia NS NS NS RARELY RARELY C, X 


Laminectomy NS NS NS RARELY RARELY -- C, E X 

Spinal fusion RARELY RARELY -- E I X Use of NS may be associated with nonunion 


Vascular NS NS NS C, E X If there is risk of or actual bleeding, avoid NS* 


Total hip replacement NS NS NS C, E, T X Use of NS is controversial 

Total knee replacement NS NS NS C, E, T X Use of NS is controversial 


NS NS NS RARELY C, E, T X 


Amputation NS NS NS C, E, T X 

Shoulder NS NS NS -- -- C, E, I, T X 

NS = NSAIDs; C = Cold; E = Exercise; I = Immobilization; T = TENS; X = Use of cognitive therapy is patient-dependent rather than procedure-dependent 

Indications for Use: Bold/Red/Shaded: Preferred based on evidence (QE=1; R=A); Italicized/Blue: Common usage based on consensus (QE=III); Plain Text: Possible Use; * = bleeding is not contraindication for 

selective COX-2 inhibitors. 




Table NS1. Acetaminophen and NSAIDs: Mechanisms of Action, Contraindications, Other Considerations 

AGENTS MECHANISMS OF ACTION CONTRAINDICATIONS OTHER CONSIDERATIONS 

Acetaminophen 

Analgesic and antipyretic 

properties due to inhibition of 

central prostaglandin synthesis; 

does not inhibit peripheral 

prostaglandin synthesis 

Hypersensitivity to drug class 

The oral route may not be available after oral-maxillofacial surgery. 

There is no good evidence that NSAIDs are more effective than high-dose 

acetaminophen for acute musculoskeletal syndromes or postoperatively 

(Gotzche, 2000; Romsing et al., 2000). 

Lacks anti-inflammatory effects 

There is good evidence that other NSAIDS are more effective than standard 

acetaminophen/codeine combinations postoperatively (Ahmad et al., 1997). 

Acetaminophen produces less postoperative bleeding complications compared 

with NSAIDs that inhibit cyclooxygenase. 

Acetaminophen does not prolong bleeding time. 

All NSAIDs 

Analgesic, antipyretic, and antiinflammatory 

Hypersensitivity to drug class 

ASA/NSAID – induced asthma 

Renal impairment 

Bleeding disorder or coagulopathy 

PUD/GERD 

IBD 

Prior or concomitant glucocorticoid use 

Use with caution if patient: 

− Has nasal polyps 

− Is elderly 

− Has congestive heart failure 

− Is hypertensive 

− Is volume depleted 

Agents with anti-platelet effects may be 

contraindicated in some craniotomies due 

to concerns related to intracranial 

bleeding. 

The peri-operative administration of NSAIDs reduces pain scores, morphine 

consumption and rehabilitation times. 

Diclofenac and ibuprofen at standard doses give analgesia equivalent to 10mg 

IM morphine (McQuay et al., 1998). 

NSAIDs have a ceiling effect with regards to analgesia (Eisenberg et al., 1994; 

Gotzche, 1993; Gotzche, 2000) and are usually ineffective as the sole analgesic 

for postoperative pain in more extensive operations. (Joris, 1996). There is no 

ceiling effect for adverse effects (Chalmers, 1988; Eisenberg et al., 1994; 

Henry et al., 1996). 

Administering NSAIDs by injection or per rectum does not appear to be any 

more effective than by mouth and may cause more harm than good (McQuay 

& Moore, 1998). 

Oral agents may not be indicated in radical neck surgery due to frequent 

limitations in oral intake. 






All NSAIDs (cont.) Aspirin use alone or in combination with other NSAIDs can lead to increased 

incidence of postoperative bleeding complications (Scher, 1996). 

For noncardiac thoracic surgery, ketorolac may be useful for reducing pain and 

inflammation associated with chest tubes (Carretta et al., 1996; Puntillo, 1996). 

There is minimal risk of renal complications when NSAIDs are given to 

patients without pre-existing renal disease, congestive heart failure, cirrhosis or 

hemodynamic instability (Lee et al., 2000). 

There is little risk of gastrointestinal bleeding with short-term perioperative use 

in healthy patients without pre-existing gastrointestinal ulceration, steroid use 

or prior heavy NSAID use. Caution should be used in all other patients. 

Use is generally not recommended in pregnant women because of potential 

cardiac effects on the fetus and tocolytic effects on labor. 

In aspirin-sensitive patients, all NSAIDs (including acetaminophen) should be 

avoided or used with caution (Stevenson, 1998). 

. 

NSAIDs have been shown to raise mean blood pressure (Johnson et al., 1994). 

Salicylates 

Aspirin 

Analgesic, antipyretic, anti-platelet 

and anti-inflammatory 

See contraindications under all NSAIDs 

Aspirin use results in a doubling of bleeding time for 4 to 7 days after 

ingestion. All patients should have their aspirin therapy discontinued at least 7 

days prior to surgery. It is not recommended for use as a postoperative 

analgesic because of its anti-platelet effects (Kallis et al., 1994; Sethi et al., 

1990; Wierod et al., 1998). 

Aspirin should be avoided in children with acute febrile illness due to the 

potential development of Reyes Syndrome. 

There is a high incidence of potentially fatal aspirin intolerance (up to 40%) in 

patients with nasal polyps, asthma and chronic urticaria (Stevenson, 1998). 

Non-acetylated 

salicylates 

(e.g., salsalate) 


See contraindications under all NSAIDs 

See other considerations under all NSAIDs. 

Non-acetylated salicylates do not affect platelet aggregation. Bleeding times 

are prolonged by non-salicylate NSAIDs and ASA, but bleeding times are not 

prolonged by non-acetylated salicylates. 






Nonspecific Cyclooxygenase (COX) inhibitors 

Diclofenac & other Analgesic, antipyretic, and antiinflammatory 

effects due to 

acetic acids 

Mefenamic acid & inhibition of COX-1 and –2, and 

other fenamates leukotriene synthesis; also antibradykinin 

and lysosomal 

Nabumetone, 

Piroxicam and other membrane stabilizing activity. 

oxicams 

Ibuprofen and other 

propionic acids, 

etodolac, ketorolac 

Cyclooxygenase-2 (COX-2)–selective inhibitors 

Celecoxib 

Rofecoxib 


effects due to 

inhibition of COX-2. 

See contraindications under All NSAIDs 

See contraindications under All NSAIDs 

Sulfonamide allergy (celecoxib) 

Ketorolac offers advantage of parenteral routes (IV/IM) of administration. 

For noncardiac thoracic surgery, ketorolac may be useful for reducing pain and 

inflammation associated with chest tubes (Carretta et al., 1996; Puntillo, 1996). 

Bleeding times are not prolonged. 

Limited evidence suggests that COX-2 inhibitors lack a cardioprotective effect. 

Rofecoxib has been associated with an increased risk of MI in comparison with 

naproxen (Bombardier et al., 2000). 

In patients with acute postoperative pain or chronic pain due to RA or OA and 

who were NOT taking low doses (



Table NS2. Acetaminophen and NSAIDs: Dosing and Pharmacokinetics 

Agent †‡ 

Dosage Regimen 

(Dose, route, frequency) 

Max Daily 

Dose Onset Peak Duration Half-life Other Considerations 

(mg) (min) (min) (h) (h) 

ACETAMINOPHEN AND NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) 

(See previous bullet section for general considerations for acetaminophen and NSAIDs.) 

Para-aminophenols 

Acetaminophen 650mg PO q4-6h 4000 15 to 30 10 to 60 4 to 6 2 Overdose may lead to fatal hepatotoxicity. 

Lacks anti-inflammatory effect. 

Can be used safely in pregnancy. 

Salicylates 

Acetylsalicylic Acid 650 mg PO q4-6h 4000 15 to 30 15 to 120 2 to 4 0.25 to 

0.3 

(ASA) 

2 to 12 

(salicylic 

acid) 

Diflunisal 

Salsalate 

Acetic Acids 

Diclofenac Potassium 

(immediate-release) 

Diclofenac Sodium (delayedrelease) 

500-1000 mg loading dose, then 1500 15 to 30 120 to 180 8 to 12 8 to 12 

250-500 mg PO q8-12h 

1000 mg PO TID or 

1500 mg PO BID 

50 mg PO TID (may give initial 

dose of 100 mg) 

Consider enteric coated formulation. 

Avoid 7 to 10 days before surgery. 

Avoid in children with febrile illness. 

3000 15 to 30 120 to 180 8 to 12 ≥ 16 Low gastric toxicity; lacks antiplatelet effect. Relatively 

selective COX-2 inhibitor. 

200 on first 

day; 150 

thereafter 

30 to 60 20 to 120 4 to 8 1 to 2 

50 mg PO TID 225 15 to 30 60 to 180 4 to 8 1 to 2 Also available in combination with misoprostil; this formulation 

(Arthrotec) reduces gastrointestinal ulcers and erosions but can 

lead to diarrhea. 

Indomethacin 25-50 mg PO q8h 200 15 to 30 60 to 120 4 to 6 4.5 to 6 May aggravate depression or other psychiatric disturbances, 

epilepsy or Parkinson’s. 

Sulindac 150-200 mg PO BID 400 < 180 120 to 240 6 to 12 7.8 A pro-drug safer for long-term use with fewer gastrointestinal 

complications. It is safer for those with renal impairment. 

Tolmetin 200 to 400 mg PO TID 2000 15 to 30 30 to 60 4 to 8 1 to 1.5 

Fenamates 

Meclofenamate 50 mg PO q4-6h 400 15 to 30 30 to 60 2 to 4 3.3 Higher incidence of GI side effects of dyspepsia and diarrhea. 

Serious side effect of hemolytic anemia has occurred. 

Mefenamic Acid 500 mg then 250 mg PO q4-6h 1000 15 to 30 120 to 240 2 to 4 2 to 4 Higher incidence of GI side effects of dyspepsia and diarrhea. 

Serious side effect of hemolytic anemia has occurred. 

Naphthylalkanones 

Nabumetone 500 mg PO BID 2000 60 to 90 150 to 240 8 to 12 22.5 to 

30 

Oxicams 

Meloxicam 7.5 to 15 mg PO QD 15 ≥ 30 240 to 300 12 to 24 15 to 20 

Pro-drug with low risk of gastrointestinal complications; 

relatively selective COX-2 inhibitor. 




Table NS2. Acetaminophen and NSAIDs: Dosing and Pharmacokinetics 

Agent †‡ 

Dosage Regimen 

(Dose, route, frequency) 

Max Daily 

Dose Onset Peak Duration Half-life Other Considerations 

(mg) (min) (min) (h) (h) 

Piroxicam 20 mg PO QD 20 60 to 300 180 to 300 ≥ 24 30 to 86 May take at least 2 weeks to achieve stable analgesia. 

Propionic Acids 

Fenoprofen 200 mg PO q4-6h 3200 15 to 30 60 to 120 2 to 4 2 to 3 

Flurbiprofen 100 mg PO BID-TID 300 60 to 90 90 6 to 8 5.7 

Ibuprofen 400 mg PO q4-6h 3200 15 to 30 60 to 120 4 to 6 1.8 to 

2.5 

Ketoprofen 50 to 75 mg PO TID-QID 300 15 to 30 30 to 120 6 to 8 2 to 4 

Naproxen 250 to 500 mg PO q12h 1500 60 to 90 120 to 240 7 12 to 15 Best tolerated of the propionic acids. 

Naproxen Sodium 275 to 550 mg PO q12h 1650 15 to 30 60 to 120 7 12 to 13 

Oxaprozin 600 to 1200 mg PO QD 1800 60 to 90 180 to 300 12 to 24 42 to 56 

Pyranocarboxylic acid 

Etodolac 200-400 PO q6-8h 1200 15 to 30 60 to 120 4 to 12 7.3 Have less gastrointestinal side effects than other non-selective 

COX-2 inhibitors. 

Pyrrolizine carboxylic acid 

Ketorolac 

20 mg PO initial dose, then 40 30 to 60 60 to 90 4 to 6 2 to 9 Use for up to 5 days maximum. 

10 mg PO q4-6h 

30mg IM/IV q 6h 120 30 60 to 120 4 to 6 2 to 9 Use for up to 5 days maximum. Only currently available 

parenteral NSAID routinely used for postoperative use. 

Available in topical form for ophthalmic pain. 

COX-2–selective Inhibitors 

Celecoxib 

† 

400 mg initially, followed by an 

additional 200-mg dose if 

needed on the first day, then 200 

mg BID 

400 60 to 120 180 12 to 24 11 Avoid in those with sulfa allergies. Even low doses of aspirin 

reduce or eliminate gastroprotective effect. Does not affect 

platelet aggregation or bleeding times. Limited evidence 

suggests that COX-2 inhibitors lack a cardioprotective effect. 

Rofecoxib 50 mg PO QD 50 60 to 90 120 to 180 24 17 Use for longer than 5 days has not been studied in treatment of 

acute pain. Even low doses of aspirin reduce or eliminate 

gastroprotective effect. Does not affect platelet aggregation or 

bleeding times. Limited evidence suggests that COX-2 inhibitors 

lack a cardioprotective effect. 

‡ 

Agents shown in bold are listed on the VA National Formulary (VANF, as of Dec. 2001); agents shown in italic are listed on the DoD Basic Core Formulary (BCF, as of 15 Nov. 2001); agents shown 

in bold italic are listed on both the VANF and BCF. Check listings for specific formulations and restrictions. 

Not all agents are FDA-approved for treatment of acute pain. Generally, agents that have a delayed onset and longer duration of action may not be suitable for treating acute post-operative 

pain. 




Table NS3. Acetaminophen and NSAIDs: Drug Interactions 

PRECIPITANT 

DRUG 

OBJECT 

DRUG 

EFFECT OF 

OBJECT DRUG 

DESCRIPTION 

Acetaminophen (APAP) Drug Interactions 

Alcohol, ethyl APAP ↑ Hepatotoxicity has occurred in chronic alcoholics following various (moderate to excessive) dose levels of 

acetaminophen. 

Anticholinergics APAP ↓ The onset of acetaminophen effect may be delayed or decreased slightly, but the ultimate pharmacologic effect is not 

significantly affected by anticholinergics. 

APAP Lamotrigine ↓ Serum lamotrigine concentrations may be reduced, producing a decrease in therapeutic effects. 

APAP Loop diuretics ↓ The effects of the loop diuretic may be decreased because APAP may decrease renal prostaglandin excretion and 

decrease plasma renin activity. 

APAP Zidovudine ↓ The pharmacologic effects of zidovudine may be decreased because of enhanced nonhepatic or renal clearance of 

zidovudine. 

APAP 

Anticoagulants, 

Oral 

↑ Acetamionphen may increase the anticoagulant effect of warfarin particularly when used in doses > 2 grams/day for 1 

week or more. 

Beta blockers, 

propranolol 

APAP ↑ Propranolol appears to inhibit the enzyme systems responsible for the glucuronidation and oxidation of 

acetaminophen. Therefore, the pharmcologic effects of acetaminophen may be increased. 

Charcoal, activated APAP ↓ Reduces acetaminophen absorption when administered as soon as possible after overdose. 

Contraceptives, 

APAP ↓ Increase in glucuronidation results in increased plasma clearance and a slightly decreased half-life of acetaminophen. 

oral 

Probenecid APAP ↑ Probenecid may slightly increase the therapeutic effectiveness of acetaminophen. 

Salicylate Drug Interactions 

Alcohol Salicylates ↑ The risk of GI ulceration increases when salicylates are given concomitantly. Ingestion of alcohol during salicylate 

therapy may prolong bleeding time. 

Ammonium 

chloride 

Salicylates ↑ Urinary acidifiers decrease salicylate excretion. 

Ascorbic acid 

Methionine 

Antacids 

Urinary 

alkalinizers 

Carbonic 

anhydrase 

inhibitors 

Salicylates ↓ Antacids and urinary alkalinizers may decrease the pharmacologic effects of salicylates. Urinary alkalinization 

increases the renal excretion of salicylic acid due to decreased tubular reabsorption of the non-ionized drug. The 

magnitude of the antacid interaction depends on agent, dose and pretreatment urine pH. 

Salicylates 

Carbonic 

anhydrase 

inhibitors 

↑ 

Salicylate intoxication has occurred after coadministration of these agents. However, salicylic acid renal elimination 

may be increased if urine is kept alkaline. Conversely, salicylates may displace acetazolamide from protein binding 

sites resulting in toxicity. Further study is needed. 

Salicylates 

Charcoal, activated Aspirin ↓ Coadministration decreases aspirin absorption, depending on charcoal dose and interval between ingestion. May be 

useful. 

Corticosteroids Salicylates ↓ Corticosteriods increase salicylate clearance and decrease serum levels. 





PRECIPITANT OBJECT EFFECT OF 

DRUG 

DRUG OBJECT DRUG 

DESCRIPTION 

Nizatidine Salicylates ↑ Increased serum salicylate levels have occurred in patients receiving high-dose aspirin (3.9 g/day) and concurrent 

nizatidine. 

Aspirin 


Oral 

↑ Therapeutic aspirin has an additive hypoprothrombinemic effect. Impaired platelet function may prolong bleeding 

time. Use with caution. 

Aspirin Heparin ↑ Aspirin can increase bleeding risk in heparin- anticoagulated patients. 

Aspirin Nitroglycerin ↑ Nitroglycerin, when taken with aspirin, may result in unexpected hypotension. Data are limited. If hypotension 

occurs, reduce the nitroglycerin dose. 

Aspirin NSAIDs ↓ Aspirin may decrease NSAID serum concentrations. Concomitant use offers no advantage and may significantly 

increase incidence of GI effects. 

Aspirin Valproic acid ↑ Aspirin displaces the drug from its protein-binding sites and may decrease its total body clearance, thus increasing the 

pharmacologic effects. 

Salicylates 

Angiotensinconverting 

enzyme 

inhibitors 

↓ 

Antihypertensive effects of these agents may be decreased by concurrent salicylate administration, possibly due to 

prostaglandin inhibition. Consider discontinuing salicylates if problems occur. 

Salicylates Beta-adrenergic 

blockers 

↓ Antitypertensive effects of beta-adrenergic blockers may be blunted by concurrent salicylate administration, possibly 

due to prostaglandin inhibition. Consider discontinuing salicylates if problems occur. 

Salicylates Loop diuretics ↓ Loop diuretics may be less effective when given with salicylates in patients with compromised renal function or with 

cirrhosis with ascites; however, data conflict. 

Salicylates Methotrexate ↑ Salicylates increase drug levels and may cause toxicity by interfering with protein binding and renal elimination of 

the antimetabolite. 

Salicylates Probenecid 

↓ Salicylates antagonize the uricosuric effect of probenecid and sulfinpyrazone. While salicylates in large doses 

(>3g/day) have a uricosuric effect, smaller amounts may reduce the uricosuric effect of these agents. 

Sulfinpyrazone 

Salicylates Spironolactone ↓ Salicylates may inhibit the diuretic effects; antihypertensive action does not appear altered. Effects depend on the 

Salicylates 

Sulfonylureas 

Insulin 

NSAID Drug Interactions 

↑ 

dose of spironolactone. 

Salicylates in doses >2 g/day have a hypoglycemic action, perhaps by altering pancreatic beta cell function. They may 

potentiate the glucose-lowering effect of these drugs. 

NSAIDs Anticoagulants ↑ Coadministration may prolong prothrombin time (PT). Also consider the effects NSAIDs have on platelet function 

and gastric mucosa. Monitor PT and patients closely, and instruct patients to watch for signs and symptoms of 

bleeding. 

NSAIDs ACE inhibitors ↓ Antihypertensive effects of captopril may be blunted or completely abolished by indomethacin. 

NSAIDs Beta blockers ↓ The antihypertensive effect of the beta blockers may be impaired. Sulindac and naproxen did not 

affect atenolol. 

NSAIDs Cyclosporine ↑ Nephrotoxicity of both agents may be increased. 

NSAIDs Digoxin ↑ Ibuprofen and indomethacin may increase digoxin serum levels. 

NSAIDs Dipyridamole ↑ Indomethacin and dipyridamole coadministration may augment water retention. 





PRECIPITANT OBJECT EFFECT OF 

DRUG 

DRUG OBJECT DRUG 

DESCRIPTION 

NSAIDs Hydantoins ↑ Serum phenytoin levels may be increased, resulting in an increase in pharmacologic and toxic effects of phenytoin. 

NSAIDs Lithium ↑ Serum lithium levels may be increased; however, sulindac has no effect or may decrease lithium levels. 

NSAIDs Loop diuretics ↓ Effects of the loop diuretics may be decreased. 

NSAIDs Methotrexate ↑ The risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity) may be increased. 

NSAIDs Penicillamine ↑ Indomethacin may increase the bioavailability of penicillamine. 

NSAIDs Sympathomimetics ↑ Indomethacin and phenylpropanolamine coadministration may result in increased blood pressure. 

NSAIDs Thiazide diuretics ↓ Decreased anthypertensive and diuretic action of thiazides may occur with concurrent indomethacin. Naproxen has 

also been implicated. Sulindac may enhance the effects of thiazides. 

Cimetidine NSAIDs ↔ NSAID plasma concentrations may be increased or decreased by cimetidine; some studies report no effect. Also, 

indomethacin and sulindac have increased ranitidine and cimetidine bioavailability. 

Probenecid NSAIDs ↑ Probenecid may increase the concentrations and, possibly, the toxicity of the NSAIDs. 

Salicylates NSAIDs ↓ Plasma concentrations of NSAIDs may be decreased by salicylates. Avoid concurrent use because it offers no 

therapeutic advantage and may significantly increase the incidence of GI effects. Use of salicylates resulted in 

decreased binding of ketorolac (2-fold increase of free drug). 

DMSO Sulindac ↓ DMSO may decrease the formation of the active metabolite of sulindac, possibly resulting in decreased therapeutic 

effect. Also, topical DMSO with sulindac has resulted in severe peripheral neuropathy. 

Diflunisal Drug Interactions 

Diflunisal Acetaminophen ↑ Administration of difunisal resulted in 50% increase in acetaminophen plasma levels. Acetaminophen had no effect 

Diflunisal 


oral 

↑ 

on difunisal plasma levels. 

Coadministration of diflunisal may increase hypoprothrombinemic effects of anticoagulants. Diflunisal competitively 

displaces coumarins from protein-binding sites. Monitor prothrombin time during and for several days after 

coadministration. Adjust dosage of oral anticoagulants as required. 

Diflunisal Hydrochlorthiazide ↑ Coadministration of diflunisal resulted in significantly increased plasma levels of hydrochlorothiazide. Diflunisal 

decreased the hyperuricemic effects of hydrochlorothiazide. 

Diflunisal Indomethacin ↑ Administration of diflunisal decreased renal clearance and significantly increased plasma levels of indomethacin. The 

combined use has also been associated with fatal GI hemorrhage. 

Diflunisal Sulindac ↓ Administration of diflunisal resulted in lowering of the plasma levels of the active sulindac sulfide metabolite by 1/3. 

↑ = Effect of object drug increased ↓ = Effect of object drug decreased ↔ = Undetermined clinical effect 


Version 1.2 



NSAIDs 

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Version 1.2 



LOCAL ANESTHETICS 

Key Points 

• Local anesthetics provide analgesia by blocking transmembrane sodium channels and thus 

impairing propagation of the nerve action potential along the axon. 

• Local anesthetics are effective for postoperative pain management when administered by local, 

regional, epidural, or intrathecal injection or infusion. 

• The combination of local anesthetics with other agents (e.g., epinephrine, clonidine, opioids, or 

mixed agonist antagonist opioids) may prolong the duration of action for many local anesthetics. 

• Allergic reactions occur mainly with the ester type local anesthetics. There may be crossover 

hypersensitivity between local anesthetics of the ester class. Amide-type local anesthetics have 

not shown cross-sensitivity with the esters. 

• Patients with cardiac disease, hyperthyroidism, or other endocrine diseases may be more 

susceptible to the toxic effects of local anesthetics. 

Pharmacologic Management: Local Anesthetics Page 62



Summary Table: Site-specific Pain Management Interventions – Local Anesthetics 




Ophthalmic -- -- RARELY LA C X 

Craniotomy -- -- LA 

Radical neck -- -- LA X 

Oral-maxillofacial -- -- LA C, I X 

Thoracotomy LA LA LA C, T X 

Mastectomy LA LA LA C, T X 

Thoracoscopy LA LA LA C, T X 

CABG RARELY RARELY 

MID-CAB RARELY LA X 

Laparotomy LA LA LA E, T X 

Laparoscopic cholecystectomy RARELY RARELY LA E, T X 

Nephrectomy LA LA LA E, T X 

Hysterectomy LA LA LA E, X 

Radical prostatectomy LA LA -- E X 

Hernia RARELY RARELY LA C, X 

Laminectomy RARELY RARELY -- C, E X 

Spinal fusion RARELY RARELY -- E I X 

Vascular LA LA LA C, E X 

Total hip replacement LA LA LA C, E, T X 

Total knee replacement LA LA LA C, E, T X 


RARELY LA C, E, T X 


Amputation LA LA LA C, E, T X 

Shoulder -- -- LA C, E, I, T X 

LA = Local Anesthetics; C = Cold; E = Exercise; I = Immobilization; T = TENS; X = Use of cognitive therapy is patient-dependent rather than procedure-dependent 

Indications for Use: Bold/Red/Shaded: Preferred based on evidence (QE=1; R=A); Italicized/Blue: Common usage based on consensus (QE=III); Plain Text: Possible Use 




Table LA1. Local Anesthetics: Mechanisms of Action, Contraindications, Other Considerations 

AGENTS 

Esters 

• Benzocaine (Americaine, Cetacaine, 

Hurricaine) 

• Chloroprocaine (Nesacaine) 

• Cocaine 

• Procaine (Novocaine) 

• Tetracaine (Pontocaine) 

Amides 

• Bupivacaine (Marcaine, 

Sensorcaine) 

• Dibucaine (Nupercainal) 

• Etidocaine (Duranest) 

• Lidocaine (Xylocaine) 

• Levobupivacaine (Chirocaine) 

• Mepivacaine (Carbocaine, 

Polocaine) 

• Prilocaine (Citanest) 

• Ropivacaine (Naropin) 

• 

MECHANISMS 

OF ACTION 

• Local anesthetics block nerve 

conduction by binding to the 

transmembrane sodium 

channels resulting in inhibition 

of sodium influx. This impairs 

propagation of the nerve action 

potential along the axon. 

• The use of vasoconstrictors 

(e.g., epinephrine) with local 

anesthetics promotes local 

hemostasis, decreases systemic 

absorption, and prolongs the 

duration of action. 

• The use of epidural local 

anesthetics (bupivacaine) with 

opioids may allow for 

comparable or improved 

analgesia with fewer side 

effects when compared with 

using either agent alone. 

CONTRAINDICATIONS 

• Hypersensitivity 

• Myasthenia gravis 

• Severe shock 

• Impaired cardiac conduction 

• Epidural and spinal anesthesia 

is contraindicated in serious 

diseases of the CNS or spinal 

cord such as meningitis, spinal 

fluid block, hemorrhage, 

tumors, polio, syphilis, 

tuberculosis, or metastatic 

lesions of the spinal cord. 

• Regional analgesia with local 

anesthetics is absolutely 

contraindicated in 

anticoagulation, bleeding 

disorders, infection, and 

allergy. 

• Regional analgesia with local 

anesthetics is relatively 

contraindicated in altered 

anatomy, inability to 

communicate, and peripheral 

neurologic disease. 

OTHER CONSIDERATIONS 

• Any local anesthetic may be employed for infiltration anesthesia. 

Choice of a specific drug is primarily based on desired duration of 

action. 

• Peripheral nerve blocks are categorized into minor (involve single 

nerves) or major (involve two or more nerves or a nerve plexus) 

types. Most local anesthetics can be used for minor nerve blocks. 

• Use of local anesthetics in epidural infusions may produce 

weakness from unwanted motor blockade, hypotension, or urinary 

retention that may require bladder catheterization. 

• Administration of local anesthetics may interfere with neurologic 

monitoring. 

• In thoracoscopy, injection of local anesthetics through the 

thoracoscope at the end of the procedure may provide pain control 

in the immediate postoperative period. 

• For infiltration and regional block anesthesia, always inject 

slowly, with frequent aspirations, to prevent intravascular 

injection. 

• Epidural analgesia is not used in thoracic cardiac surgery because 

of the frequent use of anticoagulation and the potential for 

complications. 

• Patients with cardiac disease, hyperthyroidism, or other endocrine 

diseases may be more susceptible to the toxic effects of local 

anesthetics. 

• Use with caution in severely debilitated patients and those with 

liver disease. 




Table LA2. Local Anesthetics: Pharmacologic, Pharmacokinetic, and Clinical Characteristics 

Chemical 

Group 

Esters 

Generic (Brand) 

Names† 

Procaine 

Chloroprocaine 

Clinical 

Use 

Concentration 

(%) 

Onset 

(min) 

Duration 

Plain 

Solution 

(minutes) 

Duration 

With 

Epinephrine 

(minutes) 

Recommended 

maximum 

single dose 

(mg) 

pH 

(pKa) 

of Plain 

Solution 

Infiltration 0.5-1.0 2-5 15-60 30-90 1000 5.0-6.5 

(8.9-9.1) 

Peripheral 1.0-2.0 2-5 15-30 30-60 

blocks 

1000 

Spinal 10 ND 30-60 NA 200 

Infiltration 0.5-2.0 6-12 15-30 30 800 

1000 + 

epinephrine 

Peripheral 

blocks 

1.0-2.0 6-12 15-30 30-60 1000 + 

epinephrine 

Epidural 1.5 5-15 ND 30-90 1000 + 

epinephrine 

Tetracaine Spinal 0.25-1 Up to 

15 

2.7-4.0 

(8.7-9) 

75-200 NA 15 4.5-6.5 

(8.5-8.6) 

Comments 

Use has declined because of relatively low potency, 

slow onset, and short duration of action. Currently used 

mainly for local infiltration anesthesia and differential 

spinal blocks to evaluate chronic pain patients. 

Maximum single dose 15 mg/kg and no more than 

1000 mg. Allergic reaction potential increases with 

repeated use. Metabolized by plasma 

pseudocholinesterases to para-aminobenzoic acid and 

other metabolites and excreted in the urine. 

An analog of procaine but is hydrolyzed four times 

faster. Rapid onset, brief duration, and low systemic 

toxicity. Not used for spinal anesthesia due to reports 

of neurotoxicity with sensory/motor deficits. Used in 

obstetrics because it can be metabolized by the fetal 

enzyme system. Maximum single dose 15 mg/kg and 

no more than 800 mg (1000 mg with epinephrine). 

Metabolized by plasma pseudocholinesterases. 

Metabolites excreted in the urine. 

An analog of procaine but is ten times more potent and 

toxic and is hydrolyzed four times slower. Main benefit 

is its long duration of action. Has poor diffusion 

qualities so is not a good agent for peripheral blockade 

unless combined with fast onset local anesthetics. 

Maximum single dose is 2.5 mg/kg. Used mainly for 

spinal anesthesia. Metabolized by plasma 

pseudocholinesterases to para-aminobenzoic acid. 

Metabolites are mainly excreted in the urine. 

Cocaine Topical 4.0-10.0 Slow 30-60 NA 150 NA Used topically primarily in ear, nose and throat 

procedures. Addictive, causes vasoconstriction, CNS 

toxicity, marked excitation. May cause cardiac 

arrhythmia related to sympathetic stimulation. Cocaine 

is the only local anesthetic that consistently causes 

vasoconstriction at all concentrations because it 

inhibits the uptake of norepinephrine by storage 

granules. 

Benzocaine Topical Up to 20.0 Slow 30-60 NA 200 NA Useful for topical anesthesia of the skin and mucous 

membranes. There in no applicable pH or pKa for this 

topical product because pH is an aqueous phenomenon. 

Polyethylene glycol (PEG) is used in the topical 

formulation rather than water. 





Chemical 

Group 


Names† 


Use 

Concentration 

(%) 

Onset 

(min) 

Duration 

Plain 

Solution 

(minutes) 

Duration 

With 

Epinephrine 

(minutes) 

Recommended 

maximum 

single dose 

(mg) 

pH 

(pKa) 


Solution 

Amides Lidocaine Infiltration 0.25-1.0 < 2 30-60 120 300 5.0-7.0 

(7.9) 

Prilocaine 

Peripheral 

blocks 

0.5-1.5 < 2 to 

30 

60-120 120-240 500 + 

epinephrine 

900 + 

epinephrine for 

brachial plexus 

block or 

femoral/sciatic 

block 

Epidural 1.0-2.0 5-15 ND 30-90 500 + 

epinephrine 

Epidural 

infusion 

Spinal 5.0 

with dextrose 

0.5-2.0 5-15 NA NA 1.0 mg/kg/hr 

continuous 

infusion 

ND 30-90 NA 100 

Topical 2.0-5.0 ND 30-60 NA 500 + 

epinephrine 

Infiltration 0.5-1.0 < 2 30-90 120 600 4.5 

(7.7-7.9) 

Peripheral 0.5-2.0 < 3 to 15-30 30-300 600 

blocks 

20 

Epidural 1.0-3.0 5-15 ND 60-180 600 + 

epinephrine 

Comments 

Rapid onset and moderate duration of action. 

Absorption and plasma level will vary by site of 

administration. Maximum single dose should not 

exceed 4.5 mg/kg or 300 mg (7 mg/kg or 500 mg with 

epinephrine) for infiltration and peripheral blocks. The 

maximum dose for brachial plexus block is 900 mg 

with epinephrine. Maximum spinal dose is 100 mg. 

Plasma protein binding is 60-80%. Plasma elimination 

half-life is 1.5-2.0 hours. Metabolized by the liver with 

metabolites excreted by the biliary tree, reabsorbed, 

and then excreted in the urine. Topical solutions of 2- 

4% are used for procedures involving the oropharynx, 

tracheobronchial tree, and nose. A 2% topical jelly is 

used in the urethra. A 2.5-5% ointment is used on the 

skin, mucous membranes, and rectum. A 2% viscous 

formulation is used on the oropharynx. 

An analog of lidocaine. It has a rapid onset and 

moderate duration of action. Plasma protein binding is 

55%. Metabolized by the liver to an aminophenol that 

can oxidize hemoglobin and methemoglobin, resulting 

in cyanosis. There is increased risk of 

methemoglobinemia at doses above 600 mg. Maximum 

single dose 8 mg/kg or 600 mg. 





Chemical 

Group 

Amides 

(cont.) 


Names† 

Lidocaine and 

Prilocaine 

Mepivacaine 

Bupivacaine 


Use 

Concentration 

(%) 

Onset 

(min) 

Duration 

Plain 

Solution 

(minutes) 

Duration 

With 

Epinephrine 

(minutes) 

Recommended 

maximum 

single dose 

(mg) 

pH 

(pKa) 


Solution 

Comments 

NA The cream is a eutectic mixture of lidocaine and 

Topical 2.5% and 2.5% < 60 NA NA 1000-2000 

per 10 cm 2 prilocaine. It is used as a topical anesthetic on intact 

skin for local analgesia. It is useful in dermal 

procedures such as intravenous cannulation, 

venipuncture, and split-thickness skin graft harvesting. 

A thick layer of cream is applied to intact skin and 

covered with occlusive dressing and left in place for 1- 

2 hours. Alternatively, an EMLA anesthetic disc is 

applied and left in place for 1-2 hours. Dermal 

analgesia can be expected to increase for up to 3 hours 

under occlusive dressing and to persist for 1-2 hours 

after removal of the cream. See the individual agents 

for further information. 

Infiltration 0.25-1.0 0.5-4 45-90 120 400 

500 + 

epinephrine 

Peripheral 0.5-2.0 2-30 60-120 120-300 400 

blocks 

500 + 

epinephrine 

4.5 

(7.6-7.8) 

750 for brachial 

plexus block or 


block 

Epidural 1.0-2.0 5-15 ND 60-180 100 

Infiltration 0.125-0.25 2-10 120-240 180 175 4.0-6.5 

(8.1) 

Peripheral 

blocks 

0.25-0.5 230 180-360 240-720 225-250 for 

brachial plexus 

block or 


block 

Epidural 0.125-0.375 4-17 ND 180-300 225 + 

epinephrine 

Epidural 

infusion 

Spinal 

0.0625-0.125 4-17 NA NA 0.4 mg/kg/hr 

continuous 

infusion 

0.75 in 1-15 75-200 NA 20 

dextrose 

Duration of action slightly longer than lidocaine 

without epinephrine. Useful for epidural when 

epinephrine is contraindicated. The maximum dose for 

brachial plexus block is 750 mg (10 mg/kg). Not used 

for spinal anesthesia. Plasma protein binding is 60%- 

85%. Metabolism is markedly decreased in the fetus 

and newborn so it is infrequently used in obstetrics. 

Metabolized by the liver. Metabolites undergo 

enterohepatic circulation and are excreted in the urine. 

Use with caution in patients with renal disease. 

Maximum single dose should not exceed 225 mg for 

infiltration and peripheal blocks. Has inherent 

vasoconstrictive ativity and the addition of epinephrine 

does notsignificantly alter the onset or duration of 

action. For brachial plexus blocks doses of 1.5-2 mg/kg 

or 200 mg have been used. Avoid exceeding 400 

mg/day since clinical experience with higher doses is 

lacking and drug accumulation may occur. Use in 

combination with opioids has resulted in good 

analgesia. The 0.75% solution should not be used for 

obstetrical analgesia because of reports of associated 

cardiac arrest with difficult resuscitation or death. 

Should not be used for regional IV anesthesia. Plasma 

protein binding is 82%-96%. Mean plasma elimination 

half-life is 3.5 hours. Metabolized in the liver; drug and 

metabolites eliminated in the urine. 





Chemical 

Group 

Amides 

(cont.) 


Names† 

Etidocaine 


Use 

Concentration 

(%) 

Onset 

(min) 

Duration 

Plain 

Solution 

(minutes) 

Duration 

With 

Epinephrine 

(minutes) 

Recommended 

maximum 

single dose 

(mg) 

pH 

(pKa) 


Solution 

Infiltration 0.50 2-8 120-180 180 300 Plain 

4.0-5.0 

(7.7) 

Peripheral 

blocks 

0.25-1.0 2-8 120-240 180-720 400 + 

epinephrine 

Epidural 0.5-1.0 5-15 ND 180-300 300 + 

epinephrine 

Comments 

A longer acting derivative of lidocaine that is four 

times more potent and toxic. It has a rapid onset and 

prolonged duration. It can cause profound sensory and 

motor blockade. Not used for obstetrical or spinal 

analgesia or regional IV anesthesia. Profound motor 

block is useful in surgical analgesia but makes it less 

useful in postoperative analgesia. Maximum single 

doses of plain solution and solution with epinephrine 

are 6 mg/kg not to exceed 300 mg, and 8 mg/kg not to 

exceed 400 mg. Plasma protein binding is 95%. Mean 

plasma elimination half-life is 1.5 hours. Metabolized 

in the liver. Drug and metabolites excreted in the urine. 

Dibucaine Topical 1.0 Slow 30-60 NA 50 NA Used topically in dosage forms applied to the skin 

(cream, ointment, aerosol), ear (solution), and rectum 

(suppositories). No longer marketed for spinal 

administration in the U.S. 

Ropivacaine 

Levobupivacaine 

Infiltration 0.2-.0.5 1-5 120-360 Same 200 ND 

(8.1) 

Peripheral 

blocks 

0.5-0.75 1-5 120-360 Same 250 

Epidural 0.2-0.5 10-30 ND NA 200 or 

0.4 mg/kg/hr 

continuous 

infusion 

Infiltration 0.25 2-10 ND NA 150 4.0-6.5 

(8.09) 

Peripheral 

blocks 

0.25-0.5 97%. Mean plasma 

elimination half-life is 1.3 hours. Metabolized by liver 

cytochrome P-450 enzyme system (CYP3A4 and 

CYP1A2). Metabolites eliminated in the urine and 

feces. 

ND = no data NA = not applicable 

† 

Agents shown in bold are listed on the VA National Formulary (VANF, as of Dec. 2001); agents shown in italic are listed on the DoD Basic Core Formulary (BCF, as of 15 Nov. 2001); agents 

shown in bold italic are listed on both the VANF and BCF. Check listings for specific formulations and restrictions. 




Table LA3. Local Anesthetics: Adverse Effects 

ADVERSE EFFECT 

Allergic or Dermatologic 

Reactions 

Local Tissue Toxicity 

Central Nervous System 

(CNS)Toxicity 

Cardiovascular Toxicity 

Miscellaneous Reactions 

COMMENTS 

Urticaria, pruritis, erythema, angioneurotic edema, sneezing, syncope, excessive sweating, elevated temperature, and anaphylactoid reactions have been 

reported. Allergic reactions occur mainly with the ester type local anesthetics. There may be crossover hypersensitivity between local anesthetics of the 

ester class. Use of ester local anesthetics is contraindicated in patients with para-aminobenzoic acid (PABA) allergy. True allergic reactions to the amide 

type local anesthetics are rare. The amide type local anesthetics have not shown cross-sensitivity with the esters. 

Tissue toxicity is rare when proper technique and concentrations of local anesthetics are used. Neurotoxicity may result from intraneural injections, needle 

trauma, injections of large concentrations or volumes, chemical contamination, and neural ischemia produced by local neural compression or systemic 

hypotension. 

CNS toxicity is related to blood concentration and the rate at which the concentration is presented to the nervous system. This most frequently arises from 

accidental intravascular injections or administration of an excessive dose. Ester type local anesthetics generally produce stimulant and euphoric effects. 

Amide type local anesthetics tend to produce sedation and amnesia. High plasma concentrations may initially produce CNS stimulatory effects such as 

anxiety, apprehension, restlessness, nervousness, disorientation, confusion, dizziness, blurred vision, tremors, twitching, shivering, and seizures. Seizures 

generally occur with lower blood concentrations than those required to produce cardiovascular collapse. CNS stimulation may be followed by CNS 

depression manifested by drowsiness, unconsciousness, and respiratory arrest. Commonly reported symptoms associated with increasing blood levels 

include headache, lightheadedness, numbness and tingling of the perioral area or distal extremities, tinnitus, drowsiness, a sensation of flushing or chilling, 

and blurred vision. 

Cardiovascular toxicity most frequently arises from accidental intravascular injections or administration of an excessive dose. The patient should be 

monitored for myocardial depression, hypotension, decreased cardiac output, heart block, syncope, bradycardia, and ventricular arrhythmias. Local 

anesthetics can decrease myocardial contractility, decrease rates of cardiac conduction, and decrease cardiac contractility in a dose dependent fashion. 

Local anesthetics may affect vascular smooth muscle tone resulting in either vasoconstriction or vasodilatation depending on the vascular bed affected and 

on the dose. Cardiovascular toxicity is increased by hypoxia, acidosis, hyperkalemia, and pregnancy. 

A transient burning sensation may occur at the site of injection of local anesthetics. Rarely, prolonged burning, pain, skin discoloration, tissue irritation, 

swelling, and tissue necrosis and sloughing may occur. 

Unintentional penetration of the subarachnoid space may result in high or total spinal block, hypotension, urinary retention, urinary or fecal incontinence, 

loss of perineal sensation and sexual function, paresthesia, weakness or paralysis of the lower extremities, loss of sphincter control, headache, backache, 

meningitis, meningismus, slowing of labor and increased incidence of forceps delivery, cranial nerve palsies, arachnoiditis, and persistent neurologic 

deficits. 

Adverse effects of epinephrine-containing solutions: anxiety, palpitations, dizziness, headache, restlessness, tremors, tachycardia, anginal pain, 

hypertension may occur. 


Version 1.2 



Local Anesthetics 

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Health-System Pharmacists, 2000 (electronic version). 

Lovstad R, Halvorsen P, Raeder J. A post-operative epidural analgesia with low dose fentanyl, adrenaline 

and bupivacaine in children after major orthopaedic surgery. A prospective evaluation of efficacy and 

side effects. Eur J Anaesthesiol 1997; 14(6):583-9. 

McBride WJ, Dicker R, Abajian JC, Vane DW. Continuous thoracic epidural infusions for postoperative 

analgesia after pectus deformity repair. J Pediatr Surg 1996; 31(1):105-7; discussion 7-8. 

McGlade DP, Kalpokas MV, Mooney PH, Chamley D, Mark AH, Torda TA. A comparison of 0.5% 

ropivacaine and 0.5% bupivacaine for axillary brachial plexus anaesthesia. Anaesth Intensive Care 

1998; 26(5):515-20. 

Palve H, Kirvela O, Olin H, Syvalahti E, Kanto J. Maximum recommended doses of lignocaine are not 

toxic. Br J Anaesth 1995; 74(6):704-5. 

Rawal N. Epidural and spinal agents for postoperative analgesia. Surg Clin North Am 1999; 79:313-344. 

Rygnestad T, Zahlsen K, Bergslien O, Dale O. Focus on mobilisation after lower abdominal surgery. A 

double-blind randomised comparison of epidural bupivacaine with morphine vs. lidocaine with 

morphine for postoperative analgesia. Acta Anaesthesiol Scand 1999; 43(4):380-7. 

Scherhag A, Kleemann PP, Vrana S, Stanek A, Dick W. Plasma concentrations of bupivacaine for 

continuous peridural anesthesia in children. Anaesthesist 1998; 47(3):202-8. 

Silvasti M, Pitkanen M. Continuous epidural analgesia with bupivacaine-fentanyl versus patient- controlled 

analgesia with I.V. morphine for postoperative pain relief after knee ligament surgery. Acta 

Anaesthesiol Scand 2000; 44(1):37-42. 

Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth 

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Year Book, Inc.; 1996:162-175. 


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GLUCOCORTICOIDS 

Summary 

• Glucocorticoids are potent anti-inflammatory agents that are used as adjunctive agents for the 

short-term prevention of postoperative pain following certain types of surgery. In a limited 

number of small studies, these agents have been shown to reduce postoperative pain following 

arthroscopic, lumbar disc, or other orthopedic surgery and oral surgery. Their role in management 

of postoperative pain needs further study. 

• There is limited evidence that glucocorticoids can significantly reduce requirements for other oral 

or injectable analgesics, allow earlier mobilization, reduce convalescence time, shorten the length 

of hospitalization, or reduce patient suffering, anxiety, or irritability postoperatively. 

• In addition to anti-inflammatory and analgesic activity, dexamethasone has antiemetic effects that 

may be beneficial in managing postoperative nausea or vomiting (PONV), or nausea or vomiting 

related to epidural morphine. 

• Increased risk of infection and delayed wound healing are major concerns with the postoperative 

use of glucocorticoids. There has been little published evidence of these complications, however, 

after short-term perioperative use of these agents. 

Mechanism of Action 

The mechanism of analgesic action of glucocorticoids is unclear. Several explanations for their antiinflammatory 

effects have been proposed (De Bosscher et al., 2000), including repression of 

deoxyribonucleic acid transcription (Liden et al., 2000). By inhibiting the production of chemical 

mediators of inflammation, such as prostaglandins (Muramoto et al., 1997) and bradykinin (Hargreaves & 

Costello, 1990), glucocorticoids are believed to prevent the lowering of nociceptor thresholds that occurs in 

response to surgical tissue damage. In addition, the anti-inflammatory effects of glucocorticoids are 

thought to reduce swelling and thereby prevent the compression of nerves by edematous tissue (Curda, 

1983). 

The action of glucocorticoids may involve changes in protein (mediator) synthesis, which may take time. It 

has been suggested that greater reduction in swelling after oral surgery can be obtained when 

glucocorticoids are given preoperatively as compared to postoperatively (Holland, 1987). Administration 

of dexamethasone before induction of anesthesia is more effective in preventing PONV than administration 

after anesthesia (Wang et al., 2000). There is no evidence from randomized controlled trials, however, that 

earlier rather than later administration of these agents is more effective in preventing postoperative pain. 

Therapeutic Uses Evaluated in Randomized Controlled Trials 

Pain following orthopedic surgery. Systemic or intra-articular administration of glucocorticoids before or 

immediately after arthroscopic surgery (Rasmussen et al., 1998; Wang et al., 1998), lumbar disc surgery 

(King, 1984; Watters et al., 1989), bunion surgery (Curda, 1983), or hallux valgus correction (Asaboe et al., 

1998) is effective in reducing pain or reducing the use of narcotic analgesics postoperatively. Treatment 

with a combination of high-dose, systemic methylprednisolone and bupivacaine followed by application of 

methylprednisolone to the affected nerve root has been shown to reduce pain following lumbar discectomy 

(Glasser et al., 1993). Intraoperative irrigation with dexamethasone has also been reported to be a useful 

adjunctive therapy for lumbar microdiscectomy (Foulkes & Robinson, 1990). 

A single RCT has shown that narcotic analgesic requirements following surgery for spinal stenosis can be 

significantly reduced by postoperative administration of epidural (ED) methylprednisolone acetate. 

(McNeill et al., 1995). The reduction in analgesic requirements with ED methylprednisolone was similar to 

that seen with ED administration of morphine or morphine in combination with methylprednisolone 

acetate. The use of epidural methylprednisolone acetate, however, is controversial. Given the lack of 

studies documenting its perioperative analgesic efficacy, its use cannot be routinely recommended (Nelson, 

1993). (See Adverse Effects.) 

Pharmacologic Management: Glucocorticoids Page 72

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Although intrathecal (IT) application of betamethasone before wound closure has short-term efficacy in 

reducing pain after surgery for herniated disc, the risks associated with disruption of the dural barrier 

probably outweigh the analgesic benefits of this treatment (Nelson, 1993; Langmayr et al., 1995). 

Pain following oral surgery. Systemic administration of glucocorticoids either alone (Beirne & Hollander, 

1986) or in combination with local anesthetics or NSAIDs before third molar extraction (Beirne & 

Hollander, 1986; Hooley & Francis, 1969; Skjelbred & Lokken 1982a; Holland, 1987; Neupert et al, 1992; 

Schultze-Mosgau et al., 1995) or endodontic procedures (Kaufman et al., 1994) is effective for prevention 

of postoperative dental pain. 

Pain associated with other types of surgery. Glucocorticoids used before or after neurosurgery for cerebral 

tumors, spinal metastases, head injuries, or acute spinal cord injury may indirectly relieve pain by reducing 

cerebrospinal fluid formation or tissue edema. The analgesic efficacy of glucocorticoids in these situations, 

however, has been poorly documented in the literature. 

Topical application of a combination of pramoxine and hydrocortisone was found to be ineffective in 

relieving post-episiotomy pain (Hanretty et al., 1984). 

Other clinical outcomes. A combination of preoperative methylprednisolone, intraoperative neural 

blockade, and postoperative analgesics has been found to produce other beneficial effects postoperatively, 

such as attenuate reductions in pulmonary function and mobility, and reduce plasma cascade activation 

following bowel surgery (Schulze et al., 1997). By reducing inflammation and postoperative pain, 

glucocorticoids can significantly reduce requirements for other oral or injectable analgesics (King, 1984; 

Vargas & Ross 1989; Watters et al., 1989; Foulkes & Robinson 1990; Glasser et al., 1993; McNeill et al., 

1995; Rasmussen et al., 1998), allow earlier mobilization (Vargas & Ross, 1989; Rasmussen et al., 1998), 

reduce convalescence time (Rasmussen et al., 1998), shorten the duration of hospitalization (Vargas & 

Ross, 1989; Watters et al., 1989; Foulkes & Robinson, 1990; Glasser et al., 1993), or reduce patient 

suffering, anxiety, or irritability postoperatively (Watters et al., 1989). 

Related Uses 

PONV. A recent systematic review found IV dexamethasone to be an effective antiemetic for prevention of 

early and late PONV in adults (usual dose, 8 or 10 mg) and children (usual dose, 1 or 1.5 mg/kg) (Henzi et 

al., 2000). Dexamethasone has antiemetic effects that may be beneficial in the prevention of PONV 

following major gynecologic surgery (Lopez-Olaondo et al., 1996; Liu et al., 1999; Wang et al., 2000), 

ambulatory laparoscopic tubal ligation (Wang et al. 2000), or other types of surgical procedures (Schulze et 

al., 1997; Asaboe et al., 1998; Wang et al., 1999;). For major gynecologic surgery, a minimum dose of 

2.5 mg is required for antiemetic efficacy (Liu et al., 1999). 

Nausea or vomiting related to epidural morphine. Prophylactic administration of dexamethasone (8 mg 

IV) can reduce nausea or vomiting associated with epidural injection of morphine (3 mg) (Wang et al., 

1999). 

Contraindications 

• History of allergy to glucocorticoids 

• Overt or latent tuberculosis 

• Peptic ulcer disease 

• Systemic viral or fungal infections 

• Diabetes mellitus 

• Glaucoma 

• Congestive heart failure 


Version 1.2 



Adverse Effects 

Short-term peri-operative use of glucocorticoids is generally well tolerated. Glucocorticoids may mask 

signs of infection and their immunosuppressive effects may lead to dissemination of infection. Increased 

risk of infection and delayed wound healing are major concerns with glucocorticoid therapy. There have 

been two cases of wound dehiscence reported in a randomized, nonblinded study after treatment with a 

combination of methylprednisolone IV, epidural analgesics, and IV indomethacin (Schulze et al., 1992). 

No evidence of these complications has been observed after short-term perioperative use of these agents in 

small, blinded randomized controlled trials (Frensilli et al., 1974; Skjelbred & Lokken 1982a; Curda, 1983; 

Holland, 1987; Glasser et al., 1993; Schulze et al., 1997; Rasmussen et al., 1998) or a retrospective casecontrol 

study with one-year follow-up (Vargas & Ross, 1989). 

A recurrence of pain may occur when the anti-inflammatory and analgesic effects of glucocorticoid wear 

off (Wilkinson, 1984). 

Intra-articular injections of glucocorticoids generally lack systemic adverse effects (Rozental & Sculco 

2000); however, systemic and infectious complications are possible. Adrenosuppression has been reported 

(Wicki et al., 2000). In patients with osteoarthritis, frequent repeated doses of intra-articular 

glucocorticoids has been associated with joint damage (Parikh et al., 1993; Wada et al., 1993). The 

treatment course for a specific weight bearing joint should generally be limited to no more than 2 to 3 

injections per year (Neustadt, 1992). Other adverse effects associated with intra-articular administration of 

glucocorticoids include osteonecrosis, tendon rupture, skin atrophy, and crystal-induced synovitis 

(postinjection flare) (Neustadt, 1992). 

High doses or long-term use of glucocorticoids given orally or parenterally may be associated with 

potentially serious systemic and metabolic effects, including hyperglycemia, hypokalemia, 

adrenosuppression, immunosuppression, infection, myopathy, osteonecrosis, psychosis, depression, 

dermoatrophy, cataracts, and glaucoma. Agents with mineralocorticoid activity may also cause sodium and 

water retention (see Table GC1). Adrenosuppression has been reported in patients undergoing oral surgery 

who received a single dose of dexamethasone 8 mg IV to prevent postoperative complications. Adrenal 

function returned to normal after 7 days without overt symptoms of adrenal insufficiency, probably because 

of adequate glucocorticoid activity provided by dexamethasone (Williamson et al., 1980). In a 

retrospective review, 1 of 44 patients (2.3%) who received high-dose glucocorticoids after neurosurgery for 

cerebral aneurysm and who were available for follow-up developed osteonecrosis of the hips (Sambrook et 

al., 1984). Nosocomial infections have been associated with glucocorticoid-induced immunosuppression in 

neurosurgical patients (Dauch et al., 1994). 

Adverse reactions associated with neuraxial injection of glucocorticoids peri-operatively have been rarely 

reported. Complications associated with nonsurgical use of epidural glucocorticoids include infection, 

dural tap, transient headache, and transient increase in pain (Carette et al., 1997). Infectious, aseptic, or 

chemical meningitis and adhesive arachnoiditis are also risks (Anonymous, 2000). Complications have 

occurred after intentional or inadvertent injection of glucocorticoids into the subarachnoid space (Nelson, 

1993; Hodges et al., 1998). Although systemic absorption of epidurally administered glucocorticoids is 

thought to be negligible, adrenosuppression (Jacobs et al., 1983) and Cushing’s syndrome (Knight & 

Burnell, 1980; Tuel et al., 1990) have been reported even after only single doses of methylprednisolone. 

The adrenosuppressive effects of epidural methylprednisolone acetate may be detectable for three weeks 

(Jacobs et al.,1983). 

Dose and Route of Administration 

Glucocorticoids differ in their duration of action, anti-inflammatory potency, and mineralocorticoid activity 

(Table GC1). 


Version 1.2 



Table GC1: Comparison of Glucocorticoid Agents in Order of Increasing Potency and Duration 

Approximate 

Equivalent Antiinflammatory 

Dose 

Relative 

Sodium 

Retaining 

Potency 

Plasma 

half-life 

Biologic 

half-life 

Glucocorticoid † 

(mg) (min) (h) 

Short-acting 

Cortisone 25 2 30 8 to 12 

Hydrocortisone 20 2 80 to 118 8 to 12 

Intermediate-acting 

Prednisone 5 1 60 18 to 36 

Prednisolone 5 1 115 to 212 18 to 36 

Methylprednisolone 4 0 78 to 188 18 to 36 

Triamcinolone 4 0 ≥ 200 18 to 36 

Long-acting 

Dexamethasone 0.75 0 110 to 210 36 to 54 

Betamethasone 0.60 to 0.75 0 ≥ 300 36 to 54 

Adapted from Drug Facts and Comparisons ® , 2000(Anonymous 2000) 

† 

Agents shown in bold are listed on the VA National Formulary (VANF, as of Dec. 2001); agents shown in italic are listed on the 

DoD Basic Core Formulary (BCF, as of 15 Nov. 2001); agents shown in bold italic are listed on both the VANF and BCF. 

Check listings for specific formulations and restrictions. 

The more potent glucocorticoids (methylprednisolone, triamcinolone, dexamethasone, and betamethasone) 

have been the agents most frequently used in studies of postoperative pain control. These agents have a 

longer duration of action (biologic half-life) and lack mineralocorticoid activity. 

Methylprednisolone, dexamethasone, and betamethasone are available as two types of parenteral 

preparations. One preparation is a solution with prompt onset that may be given IV (i.e., 

methylprednisolone sodium succinate [Solu-Medrol], dexamethasone sodium phosphate [Decadron 

phosphate], or betamethasone sodium phosphate [Celestone Phosphate]). The other preparation is a 

parenteral suspension with sustained activity that is not for IV use (i.e., methylprednisolone acetate [Depo- 

Medrol], dexamethasone acetate [Decadron-LA], or betamethasone sodium phosphate in combination with 

betamethasone acetate [Celestone Soluspan]). The betamethasone combination product provides prompt 

and sustained activities from the sodium phosphate and acetate salt components, respectively. 

Triamcinolone, as the acetonide, diacetate, or hexacetonide salt, is available only in long-acting parenteral 

suspensions not intended for IV use. 

Many parenteral suspensions of methylprednisolone acetate contain polyethylene glycol, which has been 

associated with neurotoxicity (Nelson, 1993). Subarachnoid injection of methylprednisolone preparations 

containing polyethylene glycol should be avoided (Nelson, 1993). The only routes of administration 

approved for methylprednisolone acetate by the FDA are IM, IA, soft tissue, and intralesional. 

Doses of the individual agents found to have postoperative analgesic efficacy in randomized controlled 

trials have varied according to indication, route, and site of administration (see Table GC2). 

Glucocorticoids may be given just before or immediately after surgery as single doses or as scheduled, 

tapering doses over several days postoperatively. 

For prevention of PONV related to abdominal total hysterectomy, administration of dexamethasone before 

induction of anesthesia has been shown to be more effective than administration after anesthesia (Wang et 

al., 2000). 


Version 1.2 



The doses of glucocorticoids when used for analgesic and antiemetic activity are shown in Table GC2 and 

Table GC3, respectively. 

Table GC2: Dosing and Routes of Administration of Glucocorticoids with Postoperative Analgesic 

Efficacy (Randomized Controlled Trials) 

Procedure Glucocorticoid † Dosing Route(s) Reference 

Arthroscopic knee 

surgery 

Lumbar disc 

surgery 

Bunion surgery 

Hallux valgus 

correction or 

Hemorrhoidectomy 

Molar extraction 

Endodontic 

procedure 

Methylprednisolone 

acetate 

Triamcinolone 

acetonide 

Dexamethasone 


sodium succinate 

(MPSS) + 


acetate (MPA) 


acetate 

Dexamethasone sodium 

phosphate 

Betamethasone 

disodium phosphate + 

acetate ‡ 

Betamethasone 

disodium phosphate / 

acetate ‡ 

Betamethasone 

Dexamethasone 




acetate 

40 mg at end of surgery IA (Rasmussen et 

al., 1998) 

10 mg at end of surgery IA (Wang et al., 

1998) 

6 mg before surgery IV then PO (Watters et al., 

by tapering PO doses. § 

and q6h after surgery 

1989) 

for 4 doses, followed 

250 mg MPSS + 160 

mg MPA at start of 

surgery, then fat graft 

soaked in 80 mg MPA 

applied to affected 

nerve root before 

wound closure 

IV + IM 

then direct 

application 

(Glasser et al., 

1993) 

40 mg at end of surgery ED (McNeill et al., 

1995) 

0.4 to 1.2 mg 

IA (Curda 1983) 

(depending on site) at 

end of surgery 

12 mg, 30 min before 

surgery 

9 mg before surgery or 

3 h after surgery 

1.2 mg on the evening 

before surgery, then 

1.2 mg q.i.d. to a total 

of 14.4 mg 

4 mg, 5 to 10 min 

before surgery 

40 mg before surgery 

or 

125 mg before 

induction of anesthesia 

32 mg, 12 h before and 

after surgery 

4 to 8 mg immediately 

after onset of local 

anesthesia 

IM 

IM 

PO 

(Asaboe et al., 

1998) 

(Skjelbred & 

Lokken, 1982a) ; 

(Skjelbred & 

Lokken, 1982b) 

(Hooley & 

Francis, 1969) 

IV (Neupert et al., 

1992) 

IV (Holland, 1987) 

(Beirne & 

Hollander, 1986) 

PO 

IL 

(Schultze- 

Mosgau et al., 

1995) 

(Kaufman et al., 

1994) 

ED = Epidural; IA = Intra-articular; IL = Intraligamentary; IT = Intrathecal; IM = Intramuscular; IV = Intravenous; 

MPA = Methylprednisolone acetate; MPSS = Methylprednisolone sodium succinate; PO = Per os (oral) 


Version 1.2 



† 

‡ 

§ 

Salt forms of glucocorticoids not shown in table were not specified. Concomitant analgesics or anesthesthetics not 

shown. 

Preparation consisted of 50% betamethasone disodium phosphate with fast onset and 50% betamethasone acetate 

with slower onset and longer duration. 

Tapering regimen: 4 mg PO q6h for 4 doses, then 2 mg PO q6h for 4 doses. 

Table GC3: Dosing and Administration of Glucocorticoids for Postoperative and Epidural 

Morphine-Related Nausea or Vomiting 

Procedure Agent † Effective Dose Route Reference 

Prevention of Postoperative Nausea or Vomiting 

Various surgeries Dexamethasone Usually 8 or 10 mg in 

adults, 1 or 1.5 mg/kg 

in children 

IV 

(Henzi et al., 

2000) 

Abdominal total 

hysterectomy or other 

gynecologic surgery 

Dexamethasone 

2.5 to 10 mg before 

induction of 

anesthesia ‡ IV (Liu et al., 

1999) 

(Wang et al., 

2000); 

(Wang et al., 

2000) 

(Lopez-Olaondo 

et al., 1996) 

Laparoscopic 

cholecystectomy 

Dexamethasone 

8 mg, 1 min before 


IV 

(Wang et al., 

1999) 

Thyroidectomy Dexamethasone 10 mg, 1 min before 


IV 

(Wang et al., 

1999) 

Hallux valgus correction or 

Hemorrhoidectomy 

Betamethasone 12 mg, 30 min before 

disodium phosphate surgery 

+ acetate § 

IM 

(Asaboe et al., 

1998) 

Prevention of Nausea or Vomiting Due to Epidural Morphine 

Abdominal total 

hysterectomy 

Dexamethasone 8 mg at end of 

surgery 

IV 

(Wang et al., 

1999) 

IM = Intramuscular; IV = Intravenous 

† 

‡ 

§ 

Salt forms of glucocorticoids not shown in table were not specified. 

One study found that administration of dexamethasone before induction of anesthesia was more effective in 

preventing PONV than administration after anesthesia (Wang et al., 2000). 

Preparation consisted of 50% betamethasone disodium phosphate with fast onset and 50% betamethasone acetate 

with slower onset and longer duration. 


Version 1.2 



Evidence 

In a limited number of small studies, these agents have been shown to reduce postoperative pain following 

arthroscopic, lumbar disc, or other orthopedic surgery and oral surgery. Their role in management of 

postoperative pain needs further study. 



1 Perioperative use of glucocorticoids as 

adjunctive analgesic therapy may be a 

consideration for arthroscopic surgery. 

Rasmussen et al., 1998 

Wang et al., 1998 

I 

I 

A 

A 

2 There is less or weaker evidence 

supporting the perioperative use of 

glucocorticoids for prevention of pain 

following lumbar disc surgery. 




following bunion surgery. 




following hallux valgus correction 

surgery. 

5 There is substantial evidence supporting 

the perioperative use of glucocorticoids 

for prevention of pain following third 

molar extraction. 

6 The use of epidural methylprednisolone 

acetate for preventing pain following 

surgery for spinal stenosis cannot be 

routinely recommended. 

7 In the case of intrathecal application of 

betamethasone for reducing pain after 

surgery for herniated disc, the risks 

associated with disruption of the dural 

barrier probably outweigh the analgesic 

benefits of this treatment. 

QE = Quality of Evidence; R = Recommendation (See Introduction) 

Watters et al., 1989 

King, 1984 

I 

II-1 

Curda, 1983 I A 

Asaboe et al, 1998 I A 

Beirne & Hollander, 1986 

Holland, 1987 

Neupert et al., 1992 

Skjelbred & Lokken, 1982a 

Schultze et al., 1995 

Hooley & Francis, 1969 

Nelson, 1993 III D 

Langmayr et al., 1995 

Nelson, 1993 

I 

I 

I 

I 

I 

I 

I 

III 

B 

B 

A 

A 

A 

A 

B 

B 

D 

E 


Version 1.2 



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EDUCATION FOR PAIN MANAGEMENT 

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GENERAL PREOPERATIVE EDUCATION 

Preoperative Questions: 

1. What understanding do you have regarding the pain following this operation? 

2. What experience do you have with postoperative pain relief? 

3. Do you have a desire for a particular type of pain treatment postoperatively? 

4. Do you have any questions about your anesthetic or postoperative pain management plan? 

5. What are your concerns about pain medication and pain relief? 

If unknown to patient and nurse, ascertain from the surgeon what type and route of analgesia will be used 

postoperatively to better focus pain education. 

What is pain? 

Pain is an uncomfortable feeling that tells you something may be wrong in your body. When there is an injury 

to your body (e.g., surgery, broken bones) or if you have a painful disease or condition (e.g., sickle-cell disease, 

arthritis, cancer), tiny nerve cells send messages to your brain. Pain medicine blocks or lessens these messages. 

Why is pain control important? 

Pain can affect your activity, appetite, sleep, energy, mood, and relationships. It can also affect your rate of 

recovery from the surgery. Pain relief allows you to start walking and doing your breathing exercises so that 

you can get your strength back faster and leave the hospital sooner after surgery. Pain relief helps you avoid 

problems such as pneumonia and blood clots, enjoy greater comfort while you heal, and may help you heal 

faster. 

Can pain be relieved? 

Pain in almost all cases can be controlled. Although pain is a common experience after surgery and with many 

types of illness, most patients with postoperative pain can be kept comfortable with simple treatment. 

If I am taking pain medications already, does it make a difference? 

Be sure to notify your health care provider if you are already taking pain medications. You may require a 

higher dose of pain medicine to relieve your pain. 

How can I help the doctors and nurses “measure” my pain? 

Use a pain scale to communicate your pain. For pain management to work, we need to have some way to help 

your doctors and nurses understand how much you are hurting. You will be asked to use a “pain rating scale” to 

do this. For example, on a scale of 0 to 10, with 0 being no pain, and 10 being the worst pain you can imagine, 

how much pain do you have right now? 

Appropriate goal for pain relief: 

Talk to your doctors and nurses about setting a pain control goal (such as having no pain that’s worse than 3 on 

the scale and being able to turn, cough, take deep breaths, walk, take care of yourself at home etc.). The goal is 

to relieve your pain without causing too many side effects. It may not be possible to eliminate all your pain 

after surgery. Our goal is to control your pain so that you are able to function well enough to walk, cough, and 

deep breathe after surgery. This will allow you to recover more easily following surgery. 

When should I ask for pain medication? 

Ask for pain medication when your pain first begins. If you know your pain will worsen when walking or 

doing breathing exercises, ask for pain medication first. It is harder to ease pain once it has taken hold. This is 

a key step in proper pain control. 

How soon after I take medicine should my pain be relieved? 

Your pain should be relieved within 30-45 minutes of taking pain medication. If it is not relieved, report this to 

your nurse or physician so that they can make prompt adjustments to your pain treatment plan. 

Education for Pain Management Page 1

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Will I become addicted to the pain medicine? 

It is very unlikely that you will become addicted to pain medication when used as prescribed by your physician. 

Studies have shown that becoming addicted to pain medication is very rare unless you already have a problem 

with substance abuse. 

How can my pain be controlled? 

Both drug and non-drug methods can be successful in helping to prevent and control pain. The most common 

methods are described below. You, your doctor, and your nurse will decide which ones are right for you. 

Medicines for Pain Relief: 

NSAIDs: Acetaminophen (e.g., Tylenol) will relieve mild to moderate pain and soreness. Aspirin and 

ibuprofen (e.g., Motrin) will reduce swelling and soreness and relieve mild to moderate pain. 

Benefits: 

• These medicines can lessen or eliminate the need for stronger medicines (e.g., morphine or another 

opioid). 

Risks: 

• Most NSAIDs interfere with blood clotting. They may cause nausea, stomach bleeding, or kidney 

problems. For severe pain, an opioid usually must be added. 

Opioids: Morphine, oxycodone, codeine, and other opioids are most often used for acute pain such as shortterm 

pain after surgery. 

Benefits: 

• These medicines are effective for severe pain and they do not cause bleeding in the stomach or 

elsewhere. 

• It is rare for a patient to become addicted as a result of taking opioids for postoperative pain. 

Risks: 

• Opioids may cause drowsiness, nausea, constipation, itching or interfere with breathing or urination. 

Local anesthetics: These drugs (e.g., bupivacaine) are given either near the incision, near nerves, or through a 

small tube in your back to block the nerves that transmit pain signals. 

Benefits: 

• Local anesthetics are effective for severe pain. 

• Injections or infusions at the incision site block pain from that site. 

• There is little or no risk of drowsiness, constipation, or breathing problems. 

• Local anesthetics reduce the need for opioid use. 

Risks: 

• Repeated injections or continuous infusions are needed to maintain pain relief. 

• Average epidural doses may cause some patients to have weakness in their legs or dizziness. 

Non-Drug Measures for Pain Relief: 

Education: Learning about the operation and the pain expected afterwards may reduce anxiety and pain 

Benefits: 

Reduces anxiety; no equipment needed. 

• There are no risks; however, patient attention and cooperation with staff are required. 

Relaxation: Simple techniques such as abdominal breathing and jaw relaxation can help to increase your 

comfort after surgery. 

Benefits: 

• Relaxation techniques are easy to learn, and they can help to reduce anxiety. 

• After instruction, you can use relaxation at any time. 


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• No equipment is needed. 

Risks: 

• There are no risks, but you will need instruction from your health care provider. 

Example: Slow Rhythmic Breathing for Relaxation 

1. Breathe in slowly and deeply. 

2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body. 

3. Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. You may wish 

to try abdominal breathing. If you do not know how to do abdominal breathing, ask your nurse for 

help. 

4. To help you focus on your breathing and breathe slowly and rhythmically: Breathe in as you say 

silently to yourself, “in, two, three.” Breathe out as you say silently to yourself: “out, two, three.” Or: 

5. Each time you breathe out, say silently to yourself a word such as ‘peace’ or ‘relax’. 

6. You may imagine that you are doing this in a place that is very calming and relaxing for you, such as 

lying in the sun at the beach. 

7. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes. 

8. End with a slow deep breath. As you breathe out say to yourself, “I feel alert and relaxed.” 

Additional points: If you intend to do this for more than a few seconds, try to get in a comfortable position in a 

quiet place. You may close your eyes or focus on an object. This breathing exercise may be used for only a 

few seconds or for up to 20 minutes. 

Physical Agents: Cold packs, support of surgical site while moving, mild exercise such as walking, massage, 

rest, heat, and TENS are some non-drug pain relief methods that might be used following surgery. 

Benefits: 

• In general, physical agents are safe and have no side effects. 

• TENS, which stands for Transcutaneous Electrical Nerve Stimulation, is often helpful; it is quick to act 

and can be controlled by the patient. 

• Walking is very beneficial in relieving gas pains. 

Risks: 

• There are few risks related to the use of physical techniques. 

• Your physician should approve the use of heat or cold after surgery. 

• If TENS is used, there is some cost and staff time involved for purchasing the machine and instructing 

patients in its use. 

Distraction: Distraction prevents or lessens the perception of pain by focusing attention on sensations unrelated 

to pain. The goals of distraction are to increase pain tolerance and perceived control and to decrease pain 

intensity. This technique can involve all the senses. 

Benefits: 

• Distraction is safe and has no side effects. 

• It can be individualized to each person's interest. 

• It can include music, videos, reading, humor, and television. 

Risks: 

• There are no risks related to the use of distraction for pain control. 

Hypnosis: Hypnosis is a state of focused attention to allow distraction from external stimuli. 

Induction of this state has been shown to improve pain management. 

Benefits: 

• Hypnosis is safe and decreases anxiety. 

Risks: 

• There is a need for a professional trained in hypnosis to assist this procedure. 

• It does not work with all patients. 


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How are pain medicines given? 

Oral Medication: Pills (tablets or capsules) and liquid taken by mouth. 

Benefits: 

• Tablets and liquids cause less discomfort than injections into muscle or fat, and they can work just as 

well. 

• They are inexpensive, simple to give, and easy to use at home. 

Risks: 

• These medicines cannot be used if nothing can be taken by mouth or if you are nauseated or vomiting. 

• There may be a delay in pain relief, since you must ask for the medicine and wait for it to be brought to 

you. Also, these medicines take time (30-60 minutes) to take full effect. 

Intramuscular (IM)/Subcutaneous (SQ): An injection or “shot” of medicine given into a muscle or fat. 

Benefits: 

• Medicine given by injection into fat or muscle is effective even if you are nauseated or vomiting; 

• Injections are simple to give. 

• They don’t require an intravenous access. 

• This technique is successfully used to control moderate to severe pain in all regions of the body. 

Risks: 

• The injection site is usually painful for a short time. 

• There are possibilities of infection, sterile abscess, or peripheral nerve injury. 

• Medicines given by injection are more expensive than tablets or liquids. 

• Pain relief may be delayed while you ask the nurse for medicine and wait for the shot to be drawn up 

and given. 

• Due to the variable absorption and the time and staff necessary to administer, other routes are 

preferred. 

IV PCA (Patient-Controlled Analgesia) / Intravenous (IV): IV is an injection or “shot” of medication given 

into a vein. IV PCA allows you to control when you get IV pain medication. When you begin to feel pain, you 

press a button to inject the pain medicine through the IV into your vein. 

Benefits: 

• Medicines given by injection into a vein are fully absorbed and act quickly. 

• This method is well suited for relief of brief episodes of pain. 

• When an IV PCA pump is used you can control your own doses of pain medicine. 

Risks: 

• A small tube must be inserted in a vein. 

• You must want to use the pump and learn how and when to give yourself doses of medicine if you use 

IV PCA. 

Regional Analgesia: Local anesthetics injections along a nerve that provide pain relief to a specific area of the 

body and a decrease in systemic side effects. 

Benefits: 

• Limiting the analgesia to a region of the body may allow for reducing or eliminating other types of 

pain medication. 

• Reducing the need for other types of pain medication may reduce the incidence of adverse effects. 

Risks: 

• This technique requires knowledgeable providers and specialized equipment. 

• If a single administration is used, there is a limited duration of action, so these patients may require 

some of the other methods of pain relief also. 


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Epidural/Spinal: Medication given by injection or through a small tube placed in your back (epidural space or 

into the spinal fluid). The tube may be connected to a pump, which delivers pain medicine. Some pumps allow 

you to press a button to inject the pain medicine while others provide continuous flow of medication. 

Benefits: 

• This method works well when you have chest surgery or an operation on the lower parts of your body. 

• These methods provide excellent pain relief with minimal side effects from the medications because 

they are given in lower doses. 

Risks: 

• Staff must be specially trained to place a small tube in the back and to watch for problems that can 

appear hours after pain medicine is given. 

• A spinal anesthetic may only provide relief for the duration of the operation and you may require 

medications by other routes after the operation. 

• You may not be allowed to walk or required to walk with assistance only while an epidural catheter is 

in place. 

• You may also experience difficulty urinating that may require a urinary catheter to be placed. 

Rectal: Medication in a suppository placed into the rectum. 

Benefits: 

• This method is inexpensive, simple to give, and easy to use at home. 

Risks: 

• Some people do not like this route. 

• There may be a delay in pain relief, since you must ask for the medicine and wait for it to be brought to 

you. 

• Also, these medicines take time (30-60 minutes) to take full effect. 

What to report to your physician or nurse: 

1. Report previous drug reactions and allergies. 

2. Report conditions such as stomach ulcers, kidney, heart or liver problems, and bleeding problems. 

3. Tell us about all other medications you are taking, including over-the-counter medicines, herbal remedies, 

vitamins, and nutritional supplements. 

4. Take your medication exactly as it is prescribed. If the pain medicine does not work as you want it to, 

TALK to your doctor, nurse, or pharmacist. 

5. DO NOT drink alcohol or take other drugs that cause drowsiness without informing your doctor or nurse. 

6. DO NOT drive if you are taking medications that produce drowsiness. 

7. DO NOT drive after the operation until your doctor says it is safe to do so. 

8. Report medication side effects immediately. 

DISCHARGE EDUCATION: 

Pain control is an important part of your recovery from surgery. Decreased pain will improve your ability to 

move and resume your normal activities. If your pain is not controlled enough for you to walk and participate 

in your own self-care, you need to report this to your physician. As you recover from the surgery, it is 

anticipated that the pain will gradually decrease over time. If the pain suddenly increases or does not decrease 

after several weeks, this should be reported to your physician. 

You may need to modify your activities or home situation for a brief time as you recover from surgery. This 

may include changing location of sleeping to minimize stair climbing, assistance with household duties and 

even personal care. Discuss these needs with your health care provider prior to discharge. 

You should continue to take the prescribed medication for your pain. 

Medicines for Pain Relief: 

Use your medication only as directed. If the pain is not relieved or if it gets worse, call your physician. 


Version 1.2 



Remember that oral medications need time to work. Most oral pain relievers need at least 30 minutes to begin 

to take effect. 

NSAIDs: Acetaminophen (e.g., Tylenol) will relieve mild to moderate pain and soreness. Aspirin and 

ibuprofen (e.g., Motrin) will reduce swelling and soreness and relieve mild to moderate pain. This medication 

is available both as a prescription and also over-the-counter. If you are taking a prescription, you should not 

take it over-the-counter. However, if you are not taking a prescription for an anti-inflammatory, you may take 

these over-the-counter medications for pain if approved by your physician. 

Benefits: 

• These medicines can lessen or eliminate the need for stronger medicines (e.g., morphine or another 

opioid). 

Risks: 

• Most NSAIDs interfere with blood clotting. 

• NSAIDs may cause nausea, stomach bleeding, or kidney problems. 

• For severe pain, an opioid usually must be added. 

Opioids: Morphine, oxycodone, codeine, and other opioids are most often used for acute pain such as shortterm 

pain after surgery. 

Benefits: 

• These medicines are effective for severe pain and they do not cause bleeding in the stomach or 

elsewhere. 

• It is rare for a patient to become addicted as a result of taking an opioid for postoperative pain. 

Risks: 

• Opioids may cause drowsiness, nausea, constipation, itching, or interfere with breathing or urination. 

• These medications can cause constipation. If you don’t have a bowel movement in two days, please 

contact your physician. Remember to drink plenty of fluids (6-8 glasses of fluids a day unless you are 

on a fluid-restricted diet). 

• These medications can cause drowsiness. Avoid driving or other activities that require alertness when 

taking opioid pain medications. 

• Do not drink any alcohol beverages when you are taking opioid pain medication. 

Local anesthetics: These drugs (e.g., bupivacaine) are given either near the incision or through a small tube in 

your back to block the nerves that transmit pain signals. During the time the surgical area is anesthetized, you 

will not be able to feel any additional injury to the area, just as you do not feel the pain from the surgery. You 

will need to be aware of injuring the area. As the medication wears off, the pain may increase. You will then 

need to use alternative means for pain control. 

Benefits: 

• Local anesthetics are effective for severe pain. Injections or infusions at the incision site block pain 

from that site. 

• There is little or no risk of drowsiness, constipation, or breathing problems. 

• Local anesthetics reduce the need for opioid use. 

Risks: 

• Repeated injections are needed to maintain pain relief. 

• Average doses may cause some patients to have weakness in their legs or dizziness. 

You may use the following methods for pain control while at home: 

Relaxation: Simple techniques such as abdominal breathing and jaw relaxation can help to increase your 

comfort after surgery. 

Benefits: 

• Relaxation techniques are easy to learn, and they can help to reduce anxiety. 

• After instruction, you can use relaxation at any time. 


Version 1.2 



• No equipment is needed. 

Risks: 

• There are no risks, but you will need instruction from your nurse or doctor. 

Example: Slow Rhythmic Breathing for Relaxation 

1. Breathe in slowly and deeply. 

2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body. 

3. Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. You may wish 

to try abdominal breathing. If you do not know how to do abdominal breathing, ask your nurse for 

help. 

4. To help you focus on your breathing and breathe slowly and rhythmically: Breathe in as you say 

silently to yourself, “in, two, three.” Breathe out as you say silently to yourself, “out, two, three.” Or: 

5. Each time you breathe out, say silently to yourself a word such as ‘peace’ or ‘relax.’ 

6. You may imagine that you are doing this in a place that is very calming and relaxing for you, such as 

lying in the sun at the beach. 

7. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes. 

8. End with a slow deep breath. As you breathe out say to yourself, “I feel alert and relaxed.” 

Additional points: If you intend to do this for more than a few seconds, try to get in a comfortable position 

in a quiet place. You may close your eyes or focus on an object. This breathing exercise may be used for 

only a few seconds or for up to 20 minutes (McCaffery & Pasero, 1999). 

Distraction: Distraction prevents or lessens the perception of pain by focusing attention on sensations 

unrelated to pain. The goals of distraction are to increase pain tolerance and perceived control and to decrease 

pain intensity. This technique can involve all the senses. 

Benefits: 

• Distraction is safe and has no side effects. 

• It can be individualized to each person's interest. 

• It can include music, videos, reading, humor, and television. 

Risks: 

• There are no risks related to the use of distraction for pain control. 

Physical agents: Cold pack, support of surgical site while moving, mild exercise such as walking, massage, 

rest, heat, and TENS are some non-drug pain relief methods that might be used following surgery. 

Benefits: 

• In general, physical agents are safe and have no side effects. 

• TENS, which stands for transcutaneous electrical nerve stimulation, is often helpful; it is quick to act 

and can be controlled by the patient. 

• Walking is very beneficial in relieving gas pains. 

Risks: 

• There are few risks related to the use of physical techniques. Your physician should approve the use of 

heat or cold after surgery. 

• If TENS is used, there is some cost and staff time involved for purchasing the machine and instructing 

patients in its use. Also, there is only limited evidence to support the effectiveness of TENS for pain 

relief in certain situations. 


Version 1.2 



EPIDURAL ANALGESIA 

+ 

HOW DOES PAIN AFFECT THE BODY? 

When you are injured, pain warns you to protect yourself and avoid further injury. However, unrelieved pain 

can be harmful, especially when you are sick or after surgery. Pain can make it difficult to take a deep breath 

and interferes with your ability to move and walk. This can result in complications and a long stay in the 

hospital. 

HOW WILL OTHERS KNOW HOW MUCH PAIN YOU HAVE? 

• Your nurses will check you often while you are receiving epidural analgesia. They will ask you to rate 

your pain on a 0 to 10 scale. A rating of 0 means you feel no pain at all, 5 means you feel a moderate 

amount of pain, and 10 means you feel the worst pain imaginable. 

• Your comfort goal is a reasonable expectation of the degree of pain relief you need to achieve to 

perform the activities needed for a rapid recovery. If you are unable to maintain this level of comfort, 

especially during activities such as deep breathing and walking, let your nurse know. The dose of pain 

medicine usually can be increased to keep you as comfortable as possible without producing 

intolerable side effects. 

WHAT ARE SOME OF THE GOALS OF PAIN MANAGEMENT WITH EPIDURAL ANALGESIA? 

• To keep pain from becoming severe and out of control. 

• To keep you comfortable so that you can sleep, deep breathe, walk, and visit with others. 

• To decrease the length of time spent in the hospital. 

HOW DOES EPIDURAL ANALGESIA WORK? 

• Pain medicine will be given by a small pump through an epidural catheter, which is a tiny tubing the 

anesthesiologist will put in your back before surgery. 

• The pump will give you a small amount of pain medicine continuously. 

• The anesthesiologist may inject pain medicine into the catheter when you request it for pain 

management, or 

• You MAY have a button that is attached to the pump that allows you to control the amount of pain 

medicine given. This is patient-controlled epidural analgesia (PCEA). You can press the button to give 

yourself a dose of pain medicine when you hurt. 

- The recovery room nurse will manage your pain for you when you arrive in the recovery room, 

then give you the PCEA button as soon as you are awake enough to manage the pain yourself. It 

is difficult to treat pain when it is severe, so it is important to "stay on top" of your pain. When 

you begin to feel some discomfort, press the PCEA button, then wait a few minutes to see if the 

dose helped to relieve the pain. If the pain has not been relieved, press the PCEA button again. 

HOW IS THE EPIDURAL CATHETER PLACED? 

• You will be positioned on your side or sitting up with your back arched out toward the 

anesthesiologist. 

• Your back will be washed with a cool soap solution. 

• The anesthesiologist will inject local anesthetic to numb the area where the catheter will go. This will 

feel like a bee sting. 

• You will feel pressure against your back while the anesthesiologist advances a needle to find the 

epidural space. 

• A very small catheter will be inserted through the needle into the epidural space, and then the needle 

will be removed. 

• The catheter will be taped to your back and up to your shoulder where it will be connected to the 

pump. 

• While the catheter is in place, you may lie on your back, turn, walk, and perform any activities your 

physician approves. 


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WHAT ARE THE SIDE EFFECTS OF EPIDURAL ANALGESIA? 

• Itching is not an allergic reaction but is a fairly common side effect of the pain medicine. Ask the 

nurse for medicine to relieve the itching when necessary. 

• Nausea can occur from pain medicine, and it also can be treated with medicine that has been 

prescribed. 

• Some patients have difficulty urinating while they are receiving epidural analgesia. Reducing the dose 

of pain medicine helps relieve this side effect, and it usually resolves on its own within 48 hours. 

Often a urinary catheter is used to prevent this side effect. 

• Pain medicine slows the bowel and can cause constipation. If your condition allows, the nurse will 

give you medicine to prevent constipation. 

• Excessive drowsiness and respiratory depression are the most serious but least common side effects of 

pain medicine. Less than 1 percent of patients experience these effects. These two side effects 

develop slowly. Nurses will be checking your sedation and breathing frequently. If detected, both are 

easily treated and corrected by decreasing the dose of pain medicine. 

• Numbness and tingling from the epidural local anesthetic is normal in and around the surgery incision 

area. Let your nurse know if numbness or tingling occurs in other areas. If you have difficulty feeling 

or moving your legs, stay in bed and call your nurse. This usually can be corrected by reducing the 

dose of pain medicine. Be sure to ask someone to help you up the first few times you walk. 

IS EPIDURAL INJECTION SAFE? 

• The pump will be programmed to give you an amount of pain medicine that is typically safe for 

someone your sex, size, age, and diagnosis or type of surgery. If this is too much, the dose of the pain 

medicine can be reduced. 

• The pump will be programmed with a safe hourly limit and safe time between doses so you cannot 

give yourself too much pain medicine too often. 

• You are the only person who will know when you are hurting and when it is necessary and safe to have 

a dose of pain medicine. Therefore, you are the only person who should press the PCEA button. Your 

family, visitors, physicians, and hospital personnel are not to press the PCEA button. 

• Let the nurse know before you take any other medicines, including the ones you usually take at home. 

HOW LONG WILL EPIDURAL ANALGESIA BE USED? 

• As your condition improves, your pain will decrease. You will find that you need to press the PCEA 

button less often as you improve. 

• The dose of pain medicine will be decreased gradually until the pump is no longer necessary and you 

are able to use a different method for taking pain medicine. 

• Your nurse or physician will remove the epidural catheter. This is a simple and painless procedure. 

______________________________________________________________________________ 

May be duplicated for use in clinical practice (McCaffery 1999). In addition to talking with patients about opioids and their side effects, 

providing written information reinforces explanations about the method of opioid delivery and other important points the patient will need 

to remember. 


Version 1.2 



IV PCA 

HOW DOES PAIN AFFECT THE BODY? 

When you are injured, pain warns you to protect yourself and avoid further injury. However, unrelieved pain 

can be harmful, especially when you are sick or after surgery. Pain can make it difficult to take a deep breath 

and interferes with your ability to move and walk. This can result in complications and a long stay in the 

hospital. 

HOW WILL OTHERS KNOW HOW MUCH PAIN YOU HAVE? 

Your nurses will check you often while you are receiving IV PCA. They will ask you to rate your pain on a 0 to 

10 scale. A rating of 0 means you feel no pain at all, 5 means you feel a moderate amount of pain, and 10 means 

you feel the worst pain you can imagine. 

Establish your comfort goal based on this rating. If you are unable to maintain this level of comfort, especially 

during activities such as deep breathing and walking, let your nurse know. The dose of pain medicine usually 

can be increased to keep you as comfortable as possible. 

WHAT ARE SOME OF THE GOALS OF PAIN MANAGEMENT WITH 1V PCA? 

• To keep pain from becoming severe and out of control. 

• To keep comfortable so that you can sleep, deep breathe, walk, and visit with others. 

• To decrease the length of time spent in the hospital. 

HOW DOES IV PCA WORK? 

• Pain medicine will be given by a small pump through your IV line. If you have surgery, the pump will be 

attached to your IV in the recovery room. 

• You will have a PCA button that is attached to the pump. You can press the button to give yourself a dose 

of pain medicine when you hurt. 

• You also may be given a small amount of pain medicine continuously. 

• The recovery room nurse will manage your pain for you when you arrive in the recovery room, then give 

you the PCA button as soon as you are awake enough to manage the pain yourself. 

• It is difficult to treat pain when it is severe, so it is important to "stay on top" of your pain. When you begin 

to feel some discomfort, press the PCA button, then wait a few minutes to see if the dose helped to relieve 

the pain. If the pain has not been relieved, press the PCA button again. 

IS IV PCA SAFE? 

The pump will be programmed to give you an amount of pain medicine that is typically safe for someone your 

sex, size, age, and diagnosis or type of surgery. If this is too much, the dose of the pain medicine can be 

reduced. 

The pump will be programmed with a safe hourly limit and safe time between doses so you cannot give yourself 

too much pain medicine too often. 

You are the only person who will know when you are hurting and when it is necessary and safe to have a dose 

of pain medicine. Therefore you are the only person who should press the PCA button. Your family, visitors, 

physicians, and hospital personnel are not to press the PCA button. 

Let the nurse know before you take any other medicines, including the ones you usually take at home. 

WHAT ARE THE SIDE EFFECTS OF IV PCA? 

Itching is not an allergic reaction but is a fairly common side effect of pain medicine. Ask the nurse for 

medicine to relieve the itching when necessary. 

Nausea can occur from pain medicine, and it also can be treated with medicine that has been prescribed. 


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Some patients have difficulty urinating while taking pain medicine. Reducing the dose of pain medicine helps 

relieve this side effect, and it usually resolves on its own within 48 hours. Pain medicine slows the bowel and 

can cause corutipation. If your condition allows, the nurse will give you medicine to prevent constipation. 

Excessive drowsiness and respiratory depression are the most serious but least common side effects of pain 

medicine. Less than 1 % of our patients experience these effects. These two side effects develop slowly. Nurses 

will be checking your sedation and breathing frequently. If detected, both are easily treated and corrected by 

decreasing the dose of pain medicine. 

HOW LONG WILL IV PCA BE USED? 

• As your condition improves, your pain will decrease. You will find that you need to press the PCA button 

less often as you improve. 

• The dose of pain medicine will be decreased gradually until the pump is no longer necessary and you are 

able to use a different method for taking pain medicine. 

__________________________________________________________________________________________ 

May be duplicated for use in clinical practice (McCaffery 1999). In addition to talking with patients about opioids and their side effects, 

providing written information reinforces explanations about the method of opioid delivery and other important points the patient will need 

to remember. 


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The Pain Trajectory Relative to the Operative Procedure 

Type of Surgery What does it feel like? 

(Quality) 

How bad is it? 

(Severity w/o pain medication) 

How long does it last? 

(Duration) 

Head & Neck Surgeries 

Eye (Opthalmic) Little nociceptive pain. Mild to Severe 

Several days 

Enucleations & retinal 

Phantom eye pain may 

surgeries produce both 

develop following 

nociceptive & 

enucleation and last for 

neuropathic. 

months to years. 

How can we control it? 

(Interventions) 

• Regional - preferred based on evidence 

• IV/PO opioids and PO NSAIDs - consensus 

• Oral pain medication-consensus 

Craniotomies Nociceptive in nature Mild to Moderate Lasts days • IM/IV opioids and NSAIDs and PO opioids – 

consensus 

• Oral medicine (Codeine preferred because of its 

lessor effect on brain/blood flow) 

• NSAIDs – controversial 

• PCA - a consideration but controversial 

Radical Neck Dissection Nociceptive & 

Neuropathic 

Moderate to severe Days to years • PCA opioids – consensus 

• Controlled with IM, IV, or PCA opiates 

Oral-Maxillofacial 

Thoracotomy 

Nociceptive & 

neuropathic 

Nociceptive & 

neuropathic 

Can develop chronic 

post-thoractomy pain 

syndrome 

Mild to severe 1-3 days (outpatients) • Cold, Immobilization - preferred based on 

evidence 

• Oral opioids, NSAIDs - consensus 

• Oral opioids and NSAIDs - following surgery 

• IM or IV – if oral not effective 

Thorax (Non-cardiac) 

Moderate to severe 

Days to weeks • Epidural, TENS - preferred based on evidence 

Months to years 

• Thoracic epidural analgesia (opioid & local 

anesthetic) - greatest beneficial effects 

• PCA opioids improve pain control vs. IM 

opioids 


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Type of Surgery 

Mastectomy 

What does it feel like? 

(Quality) 

Nociceptive & 

neuropathic 

Can develop chronic 

post-mastectomy pain 

syndrome 



Moderate to severe 


(Duration) 

Days to weeks 

Months to years 



• IV NSAIDs, IV/PCA opioids - consensus 

• IV/IM or PCA for 24 hours followed by PO 

opioids and NSAIDs 

Thoracoscopy 

Nociceptive and rarely Mild to moderate 

Days 

neuropathic 

Occasionally severe 

• IV opioids and NSAIDs - consensus 

Thorax (Cardiac) 

CABG Nociceptive Moderate to severe Days to weeks • IV opioids, NSAIDs - preferred based on 

evidence 

• IV rapidly transitioning to PCA or local 

MID-CAB Nociceptive Mild to moderate Days to weeks • IV opioids and NSAIDs - consensus 

• IV rapidly transitioning to PCA or local 

Laparotomy 

Laparoscopic 

Cholecystectomy 

Nephrectomy 

Hysterectomy 

Nociceptive (somatic 

and visceral) and 

neuropathic 



neuropathic 



neuropathic 

Nociceptive and 

neuropathic 

Upper Abdomen 

Moderate to severe Days to weeks • Epidural opioids, Regional, TENS - preferred 

based on evidence 

• PCA opioids, Exercise – consensus 

Mild to moderate Days • PO, IM, IV NSAIDs, Opioids, TENS, exercise – 

consensus 

Mild to severe Days to weeks • Epidural opioids, local – preferred based on 

evidence 

• Exercise – consensus 

Lower Abdomen/Pelvis 

Mild to severe Weeks • PCA opioids, exercise – consensus 

• IM, IV/PCA or intraspinal drug administration, 

oral opioid or NSAID often sufficient once 

bowel function has returned 

• Epidural can also be considered for abdominal 

hysterectomy 


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Type of Surgery What does it feel like? 

(Quality) 




(Duration) 



Radical Prostatectomy Nociceptive Moderate to severe Weeks • Epidural opioid, exercise – preferred based on 

evidence 

• IM, IV or PCA opiates, epidural analgesia may 

reduce pain for several subsequent weeks 

postoperative 

Hernia 


neuropathic 

Mild to severe 

Weeks, neuropathic 

pain may last weeks to 

years 

• Regional - preferred based on evidence 

• PO opioids – consensus 

• Regional anesthesia may prevent postoperative 

pain 

• Opioids combined with NSAIDS to treat pain 

Extremities and Vascular 

Vascular Nociceptive Mild to moderate Days to weeks • Epidural opioids, regional, exercise - preferred 


• Oral, IM IV/PCA, or intraspinal 

• Epidural may also be used for intra- and 

postoperative pain control 

Total Hip Replacement Nociceptive Mild to Severe Several days to weeks • Epidural opioids, regional, exercise, cold, and 

TENS - preferred based on evidence 

• IM, IV/PCA, intraspinal opioids, local 

anesthetics, may be effective 

• Continue femoral and continuous epidural gives 

better pain relief with movement 

• If anticoagulation used, epidural may need to 

be removed postoperative day #1 or sooner 

Total Knee Replacement Nociceptive Moderate to severe Days to weeks • Regional, Exercise, Cold, TENS - preferred 


• Epidural opioids – consensus 

• Continuous epidural and regional or epidural/ 

femoral blocks have better pain control than 

IM, IV/PCA 


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Type of Surgery 

Knee arthroscopy/ 


Amputation 

What does it feel like? 

(Quality) 




(Duration) 



Nociceptive Mild to moderate Days to weeks • Exercise, TENS, Cold – preferred based on 

evidence 


Neuropathic 

Moderate to severe Days to years • Exercise - preferred based on evidence 

• Epidural, Intrathecal opioids and local, 

regional – consensus 

• Treat preoperative pain aggressively 

• Postoperative epidural, intraspinal, IV, IM PO 

may be effective 

• May use oral agents in 2-3 days 

Shoulder Nociceptive Moderate to severe Weeks • Exercise, TENS, Cold, Immobilization - 

preferred based on evidence 

• Regional – consensus 

Laminectomy, 

Discetomy 

Fusion 


neuropathic 


neuropathic 

Back / Spinal Surgery 

Mild to severe Weeks • Exercise - preferred based on evidence 

• IV opioids, NSAIDs – consensus 

• IV NSAIDs, PCA, IV, IM and PO, NSAIDs 

may be effective 

• Epidural can be used for superior pain control 

• Local infiltration may be helpful 

Moderate to severe Months • Exercise, Immobilization – preferred based on 

evidence 

• IV, PCA opioids – consensus 

• PCA, VI IM with conversion to PO over days 

• Intraspinal morphine may be used to provide 

intra- and postoperative pain 


VHA/DoD CLINICAL PRACTICE GUIDELINE FOR 


APPENDIX A: 

GUIDELINE DEVELOPMENT PROCESS 

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Guideline Development Process 

The present guideline is the product of a close collaboration between the VHA and the DoD, which started 

in May 2000. The DoD has participated with the VHA in developing and disseminating several CPGs. 

The guideline will be updated at two to three-year intervals or when relevant research results become 

available. 

The current guideline for the management of postoperative pain represents hundreds of hours of diligent 

effort and consensus building among knowledgeable individuals from the VHA, DoD, academia, and 

guideline facilitators from the private sector. An experienced moderator facilitated the multidisciplinary 

working group that included anesthesiologists, internists, nurses, pharmacists, and expert consultants in the 

field of guideline and algorithm development. Many of the experts involved in developing this guideline 

have previously participated in the development of other VHA/DoD clinical practice guidelines. 

Development Process 

The process of developing this guideline was evidence-based whenever possible. Where evidence is 

ambiguous or conflicting, or where scientific data are lacking, the clinical experience of the working group 

was used to guide the development of consensus-based recommendations. The developers incorporated 

information from several existing, evidence-based guidelines into a format that would maximally facilitate 

clinical decision-making (Woolf, 1992). This effort drew, among others, from the following sources: 

• Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical 

Procedures and Trauma. Clinical Practice Guideline. AHCPR pub. No. 92-0032. Rockville, MD: 

Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health 

and Human Services. Feb 1992. 

• VHA, Pain as the 5th Vital Sign Toolkit, Washington, DC: National Pain Management 

Coordinating Committee, October 2000. 

• Pain Standards for 2001, Joint Commission on Accreditation of Healthcare Organizations, 2001, 

http://www.jcaho.org/standard/stds2001_mpfrm.html. 

Finally, many guidelines focus on a single episode of care or a single situation (e.g., management of postcolectomy 

pain). This guideline was designed to cover a broad spectrum of inpatient and outpatient 

situations, and thereby provides an overview of treatment options as well as detail about specific clinical 

approaches. 

Format of the Guideline 

The guideline is presented in an algorithmic format. There are indications that this format improves data 

collection and clinical decision-making and helps to change patterns of resource use. A clinical algorithm 

is a set of rules for solving a clinical problem in a finite number of steps. It allows the clinician to follow a 

linear approach to critical clinical information needed at the major decision points in the disease 

management process, and stepwise evaluation and management strategies that include the following: 

• Ordered sequence of steps of care 

• Recommended observations 

• Decisions to be considered 

• Actions to be taken 

The clinical experts subjected all decision points in the algorithms to simulated patients. Hypothetical 

"patients" were run through the algorithm to test whether it was likely to work in a real clinical situation. 

Based on these tests, the necessary changes were made to assure accurate clinical logic. Treatment must 

always reflect the unique clinical issues in an individual patient-clinician situation. Due to the nature of the 

algorithmic format, the specific therapies and preventive treatments are presented in separate boxes. It is 

recognized, however, that clinical practice often requires a nonlinear approach and concurrent processes 

that combine a number of different treatment modalities. 

Appendix A: Guideline Development Process Page 1

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Algorithms 

A clinical algorithm diagrams a guideline into a step-by-step decision tree. Standardized symbols are used 

to display each step in the algorithm (SMDMC, 1992). Arrows connect the numbered boxes indicating the 

order in which the steps should be followed. 

Rounded rectangles represent a clinical state or condition. 

Hexagons represent a decision point in the guideline, formulated as a question that 

can be answered Yes or No. A horizontal arrow points to the next step if the 

answer is YES. A vertical arrow continues to the next step for a negative answer. 

Rectangles represent an action in the process of care. 

Ovals represent a link to another section within the guideline. 

A letter within a box of an algorithm refers the reader to the corresponding annotation. The annotations 

elaborate on the recommendations and statements that are found within each box of the algorithm. 

Included in the annotations are brief discussions that provide the underlying rationale and the specific 

evidence tables. 

The Evidence 

The literature supporting the decision points and directives in this guideline is referenced in Evidence 

Tables and Discussions. The working group leaders were solicited for input on focal issues prior to a 

review of the literature, and a working list of questions was generated. Electronic searches of the Cochrane 

Controlled Trials Register (Cochrane Reviews) were undertaken. Full texts or abstracts of the Cochrane 

reviews were provided to the experts at the May 2000 meeting. In addition, a search was carried out using 

the National Library of Medicine’s (NLM) MEDLINE database. Papers selected for further review were 

those published in English-language peer-reviewed journals between 1980 and 2000. Preference was given 

to papers based on randomized, controlled clinical trials, or nonrandomized case-control studies. Studies 

involving meta-analysis were also reviewed. 

In addition, the assembled experts suggested numerous additional references. Copies of specific articles 

were provided to participants on an as-needed basis. This document includes references through the year 

2000. More recent information will be included in the next guideline update. 

A complete bibliography of all the sources used in the development of the annotations and discussions is 

provided. 

Rating the Evidence 

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence 

derived from systematic research. The working group reviewed the articles for relevance and graded the 

evidence using the rating scheme published in the U. S. Preventive Service Task Force Guide to Clinical 

Preventive Services, Second Edition (USPSTF, 1996), displayed in Table 1. The experts themselves 

formulated Quality of Evidence (QE) ratings after an orientation and tutorial on the evidence grading 

process. Each reference was appraised for scientific merit, clinical relevance, and applicability to the 

populations served by the Federal health care system. The QE rating is based on experimental design and 

overall quality. Randomized controlled trials (RCT) received the highest ratings (QE=I), while other welldesigned 

studies received a lower score (QE=II-1, II-2, or II-3). The QE ratings are based on the quality, 

consistency, reproducibility, and relevance of the studies. 


Version 1.2 



Grade 

I 

II-1 

II-2 

II-3 

III 

Table 1. Quality of Evidence Rating Scheme (USPSTF, 1996) 

Quality of Evidence (QE) 

Description 

Evidence is obtained from at least one properly randomized controlled 

trial (RCT). 

Evidence is obtained from well-designed controlled trials without 

randomization. 

Evidence is obtained from well-designed cohort or case-controlled 

analytical studies, preferably from more than one center or research 

group. 

Evidence is obtained from multiple time series with or without the 

intervention. Dramatic results in uncontrolled experiments (such as the 

results of the introduction of penicillin treatment in the 1940’s) could 

also be regarded as this type of evidence. 

Opinions of respected authorities are based on clinical experience, 

descriptive studies and case reports, or reports of expert committees. 

The U. S. PSTF grading process suggests assigning a second grade that reflects the strength of the 

recommendation (SR) for each appraised study. The evidence grade score (i.e., the SR) reflects the 

significance of the evidence as drawn from the scientific studies, but does not always reflect the importance 

of the recommendation to individual patient care. Often, the most basic patient management questions and 

well-accepted care strategies are the most difficult to test through RCTs (i.e., QE = I), especially when 

experimental design puts patients at risk. For example, no RCTs have been conducted to quantify the value 

of administering supplemental oxygen to a patient who presents with an AMI. 

In lieu of the SR rating, the recommendation rating (R), using a rating scale from A to E has been 

formulated. The specific language used to formulate each recommendation conveys panel opinion of both 

the clinical importance attributed to the topic and the strength of evidence available. When appropriate and 

necessary, expert opinion was formally derived from the working group panel to supplement or balance the 

conclusions reached after reviewing the scientific evidence. 

The rating of R (displayed in Table 2) is influenced primarily by the significance of the scientific evidence. 

Other factors that were taken into consideration when making the R determination are standards of care, 

policy concerns, and cost of care, and potential harm. 

Grade 

A 

B 

C 

D 

E 

Table 2. Recommendation Rating Scheme 

Recommendation (R) 

Description 

A strong recommendation, based on evidence or general agreement, that 

a given procedure or treatment is useful/effective, always acceptable, 

and usually indicated. 

A recommendation, based on evidence or general agreement, that a 

given procedure or treatment may be considered useful/effective. 

A recommendation that is not well established, or for which there is 

conflicting evidence regarding usefulness or efficacy, but which may be 

made on other grounds. 

A recommendation, based on evidence or general agreement, that a 

given procedure or treatment may be considered not useful/effective. 

A strong recommendation, based on evidence or general agreement, that 

a given procedure or treatment is not useful /effective, or in some cases 

may be harmful, and should be excluded from consideration. 


Version 1.2 



This rating scheme is consistent with the rating system used in all ACC/AHA guidelines, as well as the 

system used by the VA Pharmacy Benefits Management (PBM) in the VHA/DoD Guideline for 

Pharmacologic Management of Chronic Heart Failure. 


Version 1.2 



Appendix A: Guideline Development Process 

References 

Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and 

Trauma. Clinical Practice Guideline. AHCPR pub. No. 92-0032. Rockville, MD: Agency for Health 

Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb 

1992. 

Cochrane Reviews, Cochrane Controlled Trials Register at http://www.update-software.com/cochrane. 

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Pain Standards for 2001, 2001, 

http://www.jcaho.org/standard/stds2001_mpfrm.html. 

NHMRC, Commonwealth of Australia, National Health and Medical Research Council, Acute Pain 

Management: Scientific Evidence, 1999, 

http://www.health.gov.au/nhmrc/publicat/synopses/cp57syn.htm. 

SMDMC, Proposal for clinical algorithm standards, Society for Medical Decision Making Committee on 

Standardization of Clinical Algorithms, In: Medical Decision Making, 12(2): 149-54. 

USPSTF, Guide to Clinical Preventive Services. 2 ed. Baltimore: Williams and Wilkins; 1996. 

VA 1996 External Peer Review Program. Contract No. V101(93) P-1369. 

VHA Directive 96-053 (August 29, 1996). Roles and Definitions for Clinical Practice Guidelines and 

Clinical Pathways. 

VHA, Pain as the 5th Vital Sign Toolkit, Washington, DC: National Pain Management Coordinating 

Committee, October 2000. 

Woolf SH. Practice guidelines, a new reality in medicine II. Methods of developing guidelines. Archives 

of Intern Med 1992;152: 947-948. 




APPENDIX B: 

PARTICIPANT LIST 

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Participant List 

Phyllis K. Barson, MD 

Chair Dept. of Anesthesia 

Dimension Surgery Center 

1741 Overlook Drive 

Silver Spring , MD 20903 

301-439-9640 

301-439-0560 (fax) 

ssolomon22@aol.com 

Laxmi N. Berwa, MD 

Medical Oncologist 

Private Practice 

7700 Old Branch Avenue 

Clinton, MD 20735 

301-868-9066 

301-868-4989 (fax) 

John Brehm, MD 

Medical Director 

West Virginia Medical Institute 

3001 Chesterfield PL 

Charleston, WV 25304 

800-642-8686 x2238 

304-346-9863 (fax) 

jbrehm@wvmi.org 

Thomas Calhoun, MD 

Associate Medical Director 

Delmarva Medical Foundation 

1620 L Street, NW, Suite 1275 

Washington, DC 20036 

202-293-9650 or 

202-293-3253 

202-291-2371 (fax) 

tcalhoun@dfmc.org 

Mike Cantor, MD, Ethics 

White River VAMC 

West Roxbury, MA 02132 

Junction , VT 

617-323-7700, ext.6646 

617-363-5708 (fax) 

michael.cantor@med.va.gov 

Michael Craine, PhD 

Director, Interdisciplinary Pain Team 

1055 Clermont Street (116B) 

Denver, CO 80220 

303-399-8020, ext. 2577 

303-393-5076 (fax) 

michael.craine@va.med.gov 

Mary Dallas, MS, PT, CWS 

Physical Therapist/Research 

West Haven VAMC 

950 Campbell Avenue 

Mail Stop 117 

West Haven, CT 06515-2700 

203-932-5711, ext. 2885 

203-937-4707 (fax) 

mary.dallas@med.va.gov 

Mark Enderle, MD 

Chief of Staff 

VAMC 

1100 N. College Ave. (11) 

Fayetteville, AR 72703 

501-444-5050 

501-444-5089 (fax) 

mark.enderle@med.va.gov 

Rosalie Fishman, RN, MSN, CPHQ 

Clinical Coordinator 

Birch & Davis Holdings, Inc. 

8905 Fairview Road 

Silver Spring, MD 20910 

301-650-0218 

301-650-0398 (fax) 

rfishman@birchdavis.com 

Francine Goodman, PharmD, BCPS 


Pharmacy Benefits Management 

Strategic Health Care 

P.O. Box 126 

Hines, IL 60141 

720-344-7340 

720-344-6731 (fax) 

fdcgoodman@qwest.net 

Geoffrey Grammer, MD 

Internal Medicine/Psychiatry 

Walter Reed Army Medical Center 

6900 Georgia Avenue, NW 


301-540-5096 

grammer@worldspy.net 

Susan Hagan, ARNP, MS 

Coordinator, Pain Programs 

James A. Haley VA Hospital 

13000 Bruce B. Downs Blvd (117) 

Tampa, FL 33612 

813-972-2000, ext. 6094 

813-978-5988 (fax) 

susan.hagan@med.va.gov 

Appendix B: Participant List Page 1

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Cheryl Haley, RN, MA, CCM 

Senior Consultant 




301-650-0311 

301-650-0398 (fax) 

chaley@birchdavis.com 

Clark Holmes, MD 

Family Practice & Geriatrics 

3001 Hospital Drive 

Cheverly, MD 20785 

301-618-3462 

Acho53133@aol.com 

Sarah Ingersoll, RN, MS, MBA 

Network Coordinator 




626-796-4745 

626-564-0245 (fax) 

singerso@hsc.usc.edu 

Arthur Kaufman, MD 

Medical Director 




301-650-0268 

301-650-0398 (fax) 

akaufman@birchdavis.com 

Andrew Kowal, MAJ, MC, USA 

Chief, Pain Clinic 

Madigan Army Medical Center 

10907 SW 232 Street 

Vashon, WA 98070 

253-968-1085 

253-968-0525 (fax) 

yakowal@nwlink.com 

Paul M. Lambert, DDS 

Chief, Dental Service 

Dayton VAMC 

4100 W. Third Street (160) 

Dayton, OH 45428 

937-262-2102 

937-267-5355 (fax) 

lambert.paul_m@dayton.va.gov 

Thomas Larkin, MAJ, MC, USA 

Department of Anesthesia 


6900 Georgia Avenue 


202-782-2929 

202-782-4056 (fax) 

tmlarkin@hotmail.com 

Patricia Lee, RN, DNSc. 

VA Greater LA Health Care System 

11301 Wilshire Blvd. (10H) 

Los Angeles, CA 90073 

310-268-3560 

310-268-4793 (fax) 

patricia.lee2@med.va.gov 

Tamara Lutz, RN, MN, CPHQ 

Nurse Manager 

USA MEDDAC 

Bldg. 576 

Fort Eustis, VA 23604 

757-314-7621 

757-314-7591 (fax) 

tamara.lutz@na.amedd.army.mil 

Louise Nelson, RN 

Education and CQI Coordinator 

West Virginia Medical Institute, Inc. 

3001 Chesterfield Place 

Charleston, WV 25304 

800.642.8686 x2261 

304-346-9863 (fax) 

inelson@wvmi.org 

Richard Rosenquist, MD 

Associate Professor of Anesthesia 

Director, Pain Medicine Division 

University of Iowa 

200 Hawkins Drive 

Iowa City, IA 52242 

319-356-2633 

319-356-2940 (fax) 

richard-rosenquist@uiowa.edu 

Jack Rosenberg, MD 

Clinical Assistant Professor, Anesthesia 

Ann Arbor VAMC 

2215 Fuller Road 

Ann Arbor, MI 48105 

734-936-4280 

734-761-5398 (fax) 

jackrose@umich.edu 


Version 1.2 



Diana Ruzicka, RN, MSN, AOCN, CNS 

Assistant Deputy Commander for Nursing 

McDonald Army Community Hospital 

206 Monty Manor 

Yorktown, VA 23693 

757-314-7536 

757-314-7661 (fax) 

dianaruz53@aol.com. 

Alice M. Savage, MD, PhD 

Consultant to DVA 

P.O. Box 149 

Windsor, MA 04363 

207-445-4903 

sav1121age@pivot.net 

Charles Sintek, MS, RPh, BCPS 

Manager/Director, Pharmacy Practice Residency 

Denver VAMC 

1055 Clermont St. (119) 

Denver, CO 80220 

303-399-8020, ext. 2420 

303-393-4624 (fax) 

charles.sintek@med.va.gov 

David Spencer, MD 

Infectious Disease 

5204 Chandler St. 

Bethesda, MD 20814 

301-493-8609 

301-493-8602 (fax) 

spencemd@ix.netcom.com 

Oded Susskind, MPH 

P.O.Box 112 

Brookline, MA 02146 

617-232-3558 

617-713-4431 (fax) 

oded@tiac.net 

Jane H. Tollett, PhD, RN 

National Director, Pain Management Strategy 

VHA Headquarters (114) 

810 Vermont Ave., NW 


202-273-8537 

202-273-9131 (fax) 

jane.tollett@mail.va.gov 

Dennis C. Turk, PhD 

Professor of Anesthesiology and Pain 

Research 

University of Washington School 

Of Medicine 

Dept. of Anesthesiology 

P. O. Box 356540 

Seattle, WA 98195 

206-616-2626 

206-543-2958 (fax) 

turkdc@u.washington.edu 

Hal Wain, MD 

Chief Psychiatry Consultation Liaison Service 


6900 Georgia Avenue, NW 


202-782-9949 

202-782-8396 (fax) 

hjwain@erols.com 

Timothy Ward, MD 

Chief, Oral Maxillofacial Surgery 

Gainesville VAMC 

1600 SW Archer Road 

Gainsville, FL 32608 

352-379-4040 

352-379-7450 (fax) 

timothy.ward@med.va.gov 

Debby Walder, RN, MSN 

Performance Management Facilitator 

Department of Veterans Affairs 

810 Vermont Avenue, NW 


202-273-8336 

202-273-9030 (fax) 

debby.walder@mail.va.gov 

Christine D. Winslow 

Project Manager 

ACS, Inc. 

3 Skyline Place, Suite 600 

5201 Leesburg Pike 

Falls Church, VA 22041 

703-998-4981 

703-820-7363 (fax) 

cwinslow@birchdavis.com 




APPENDIX C: 

BIBLIOGRAPHY 

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BIBLIOGRAPHY 

Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and 

Trauma. Clinical Practice Guideline. AHCPR pub. No. 92-0032. Rockville, MD: Agency for Health 

Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb 

1992. 

Agency for Health Care Policy and Research (AHCPR). AHCPR Clinical Practice Guideline, Acute Pain 

Management: Operative of Medical Procedures and Trauma. U. S. Department of Health and Human 

Services. 1992. 

Agency for Health Care Policy and Research (AHCPR). Pain Control After Surgery-A Patient Guide. 

Rockville, Maryland: AHCPR, Public Health Services, U.S. Department of Health and Human 

Services, February 1992 Report No.: 92-0021. 

American Hospital Formulary Service (AFHS) Drug Information. Bethesda: American Society of Health- 

System Pharmacists, Inc.; 2000. 

Ahmad N, Grad HA, Haas DA, Aronson KJ, Jokovic A, Locker D. The efficacy of nonopioid analgesics for 

postoperative dental pain: a meta-analysis. Anesth Prog 1997; 44(4):119-26. 

Ali J, Yaffe CS, Serrette C. The effect of transcutaneous electric nerve stimulation on postoperative pain 

and pulmonary function. Surgery 1981; 89(4):507-12. 

Al-Kaisy A, McGuire G, Chan VW, Bruin G, Peng P, Miniaci A, Perlas A. Analgesic effect of interscalene 

block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery. Reg Anesth Pain Med 

1998; 23(5):469-73. 

Allen JG, Denny NM, Oakman N. Postoperative analgesia following total knee arthroplasty: a study 

comparing spinal anesthesia and combined sciatic femoral 3-in-1 block. Reg Anesth Pain Med 1998; 

23(2):142-6. 

Amar, D. Prevention and management of dysrhythmias following thoracic surgery. Chest Surg Clin N Am 

1997 Nov; 7(4):817 – 29. 

American Society of Anesthesiologists, US House of Delegates, Standards for Postanesthesia Care, 1994, 

http://www.asahq.org/Standards/02.html#3. 

American Society of Regional Anesthesia. Recommendations for Neuraxial Anesthesia and 

Anticoagulation 1998. Consensus Conference of the American Society of Regional Anesthesia. 

http://www.asra.com/items_of_interest/consensus_statements 

Andrews JR. Posterolateral rotatory instability of the knee: surgery for acute and chronic problems. Phys 

Ther 1980; 60(12):1637-9. 

Anonymous. Celebrex Prescribing Information. Chicago, IL: G.D. Serle & Co. 

Anonymous. Chirocaine Prescribing Information. Stanford, CT: Purdue Pharmacology LP. 

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